Lawrence M. Roth

Carcinoid-islet cell tumors of the duodenum: Report of twenty-one cases

Abstract A series of twenty-one carcinoid-islet cell tumors of the duodenum is reported. Eighteen were found at operation, and three were found incidentally at autopsy. Among those patients who came to operation, thirteen had duodenal ulcers, four had polypoid lesions of the duodenum, and one had obstructive jaundice due to an invasive tumor at the ampulla of Vater. Nine patients with duodenal ulcer had evidence of endocrine activity, eight of these had the Zollinger-Ellison syndrome, and one had an elevated level of 5-hydroxyindoleacetic acid in the urine. Six patients had multiple endocrine adenomatosis or evidence of neural ectodermal dysplasia. Seven tumors behaved in a malignant fashion and six of these had endocrine activity. The malignancy of only one tumor could be determined on histologic grounds alone. The remainder were diagnosed by lymph node metastasis or local recurrence. Endocrine activity, mucosal ulceration overlying the tumor, and continued secretion of highly acid gastric contents after excision of the tumor suggested the presence of metastases or multiple tumors. Tumors not associated with a duodenal ulcer were treated by simple excision if they had not metastasized and by pancreaticoduodenectomy if malignant. Tumors associated with an uncomplicated duodenal ulcer were treated by subtotal gastrectomy and excision of the tumor. Although two patients in this series were cured of the Zollinger-Ellison syndrome by partial gastrectomy and excision of the tumor, two patients died after partial gastrectomy. Six of the eight patients with gastrin-producing tumors had either lymph node metastasis or associated pancreatic tumors. For this reason, unless gastrin levels can be shown to fall to normal after resection of a duodenal tumor, we believe total gastrectomy is the procedure of choice in patients with the Zollinger-Ellison syndrome of duodenal origin just as it is with ulcerogenic tumors of the pancreas.

Proliferating Brenner tumors

The great majority of Brenner tumors are benign, but a few are frankly malignant. The rare proliferating Brenner tumor is a third variant intermediate between the benign and malignant forms. Characteristic areas of this tumor show an unusual degree of epithelial proliferation and morphologically resemble low‐grade (papillary) transitional cell carcinoma of the urinary bladder. The papillary tumor tends to grow within cystic spaces, and the epithelial component does not invade the tumor stroma. In our 3 cases, adjacent areas of typical Brenner tumor were observed. The tumors were all confined to the ovary, and none has recurred or metastasized. In one case, the patient has been free of tumor for 8 years. These tumors give additional support to the concept that Brenner tumors are composed of epithelium of urinary tract (urothelial) type.

Ovarian stromal tumors containing leydig cells. II. Pure leydig cell tumor, non‐hilar type

Rare benign neoplasms occur which are composed solely of Leydig cells derived from ovarian stroma rather than from preexisting hilus cells of the mesovarium. Two such tumors are described and two are noted in the literature although others, difficult to identify, undoubtedly exist. They are closely related to the stromal‐Leydig cell tumor but are not multifocaland lack the thecoma‐like stromal component. Both types of neoplasm occur in menopausal or post‐menopausal women and are likely to be associated with masculinization. They are related to each other as the stromal luteoma is related to the partly luteinized theca cell tumor. The presence of crystalloids of Reinke in some of the lipid cells identifies the lipid cell component of the tumor as Leydig cells. Similar tumors lacking crystalloids, in fact, may be Leydig cell tumors but in the absence of definitive diagnostic criteria are best classified as lutein cell tumors.

The Brenner tumor. A clinicopathologic study of 57 cases.

An unselected series of 57 cases of Brenner tumor is reported. The tumors occurred at a mean age of 49 years. Most were discovered as incidental findings during surgery for other pelvic disorders. A few Brenner tumors were symptomatic due to their large size, but none were diagnosed preoperatively. The incidence of bilateral tumors was 7%. No malignant Brenner tumors occurred in our series. The Brenner tumor is best considered as a tumor composed of epithelium of urinary tract (urothelial) type. In many cases, the tumor appears to arise in close relationship to the coelomic epithelium of the ovary. The tumor may occur either in the cortex or in the medullary region adjacent to the hilus. In the cortex, it may arise from Walthard nests or coelomic inclusion cysts, and, in the hilus, it may arise from the rete ovarii or mesonephric remnants. The ovarian stroma responds to the epithelial proliferation and forms the stroma of the tumor. The tumor stroma may on occasion produce clinically significant quantities of steroid hormones. This function appears to correlate best with stromal luteinization and a large content of doubly refractile lipid.

Carcinoid-islet cell tumor of the duodenum and associated multiple carcinoid tumors of the ileum. An electron microscopic study.

Light and electron microscopic studies were done on a carcinoid‐islet cell tumor of the duodenum and 8 carcinoid tumors of the ileum which were surgically excised from a patient with achalasia and a duodenal ulcer. By light microscopy, the duodenal tumor resembled both an islet cell tumor and a carcinoid of the type found in tissues of foregut origin; the ileal tumors had the typical characteristics of carcinoids of midgut origin. On electron microscopy, some cells of the duodenal tumor contained small round granules, which resemble the delta cell granules of the normal islets of Langerhans and the granules present in gastric carcinoid tumors. Other cells in the duodenal tumor contained large granules of low electron density. The ileal tumors contained polymorphic elongated secretory granules that were believed to contain serotonin. The association of this duodenal tumor, which had morphological characteristics of both a carcinoid and an islet cell tumor, with multiple carcinoids of the ileum and with a duodenal ulcer can be interpreted as giving further support to the concept that such duodenal tumors are related both to carcinoid and islet cell tumors.

Fine structure of the brenner tumor

The epithelium of the Brenner tumor resembles that of the urinary tract, and some authors consider Brenner tumors to be composed of a urothelial‐type of epithelium. A once popular viewpoint was that the Brenner tumor was a variant of the granulosa cell tumor. We have studied the fine structure of an ovarian Brenner tumor removed from a 65‐year‐old woman, and compared it with the fine structure of urinary tract epithelium and granulosa cells of the graafian follicle. The epithelial component of the Brenner tumor showed a number of the same structural features observed in urinary bladder epithelium. The cells showed no resemblance to granulosa cells of the graafian follicle.

Uterine and/or ovarian tumors weighing 25 pounds or more: A review of the literature in English since 1946☆

Abstract At the 1946 meeting of The Central Association of Obstetricians and Gynecologists, the patient with the 55 pound myomatous uterus managed on the Tulane Unit at the Charity Hospital of Louisiana at New Orleans was reported. The reasons for this communication are: first, to record the follow-up of that patient; second, to review the literature in English since then on uterine and/or ovarian tumors weighing 25 lbs. or more (11.37 kg.); third, to advocate that sizable tumors be coded in medical records so that data will be easily retrievable. In preparation of this paper we wrote to the chairmen of departments of obstetrics and gynecology listed in the 1968–1969 Association of American Medical Colleges Directory. Their replies indicate the necessity for such a procedure. This was further confirmed by the letters received from the members of the Conrad G. Collins Obstetric and Gynecologic Society of Tulane University.