In the intestine, and particularly in the rectum, carcinoma proceeds also from the mucous glands, and tends constantly to extend at its periphery and involve the entire lumen of the bowel. It seems to be inseparable from a tendency to contraction of the gut and consequent annular stricture. Ulceration, favored by surface irritation and infection, occurs almost always early. Above the rectum it usually occurs in the neighborhood of the sigmoid flexure. Cripps has observed that when cancer of the rectum spreads downward and involves the anus, it loses its typical glandular character and assumes the type of epithelioma, or squamous-cell cancer. In these cases the pelvic and mesenteric lymphatics are infiltrated and metastatic affections are common.
Carcinoma may appear in any portion of the uterus, but is more common in the lower than in the upper half. It assumes the type of the cervical glands, spreads rapidly, infiltrates widely, ulcerates early, and disseminates frequently. By extension of ulceration the formation of urinary and of fecal fistulæ is common. Pyosalpinx and hydrosalpinx are also favored, while the spread of the disease is, in fact, more common when it involves the cervix than when it involves the uterine fundus.
Malignant Chorion Epithelioma.
—This has also been called deciduoma malignum, a malignant growth of chorionic epithelium. Inasmuch as this tumor also includes a syncytial layer it has been known as syncytioma. Such tumors usually contain elements derived from both layers of the chorion. They follow pregnancy, generally within a few months, and are often preceded or accompanied by a hydatidiform mole. This growth constitutes a malignant neoplasm. It pertains to ulcerating uterine growths characterized by early extensive metastasis, which prove fatal. It has been shown that similar growths occur not only in the uterus but also in the testicle, and thus the scope of the term has been much enlarged. In its biology it resembles the sarcoma; in its histology, the carcinoma. It is more malignant than any other known growth. (See [Plate XXVIII].)
Occurring within the uterus its most important clinical feature is a tendency to frequent and alarming hemorrhage. When occurring about the testicle this trouble rapidly becomes fungoid, bleeding easily and excessively, the lungs being among the first organs to show metastasis, which takes place through the blood as well as the lymphatic vessels, for the cells of these growths seem to penetrate the capillaries. By the time a diagnosis is made a case is likely to be too far advanced to admit of radical treatment. If scrapings could be examined early, shreds of syncytioma would be found, and it might be possible that a complete hysterectomy would be of use.
Metastatic nodules consist mostly of round, dark masses presenting a more or less pronounced fibrous structure. These are generally found in the lungs and cerebrum, where the vessels are large and the tissues soft. There is usually a sharp contrast between such a tumor and the surrounding tissues. The time which elapses between delivery and the appearance of the growth is from three to ten weeks. The tumor rapidly spreads to the upper portion of the vagina. The trouble probably begins some time before delivery.
The latest tendency among pathologists is to refer a growth of this kind to the teratomas. In women this tumor is particularly a teratoid growth, some cells of the fecundated ovum giving rise to neoplasms, while the ovum itself thus derived may misdevelop into a hydatidiform mole. The tumor may be properly regarded as consisting in effect of fetal cells; it is built up of these cells, without bloodvessels and connective tissue, and so belongs to a class by itself. Occurring in women it is almost always a consequence of pregnancy; occurring in the testicle or in the ovary it should be regarded as proceeding from ectodermal cells. For their treatment the earliest and most radical measures only will suffice.
Suprarenal Epithelioma; Hypernephroma.
—Grawitz has distinctly established the right of these tumors to separate consideration, for he first determined their origin and identity. Hypernephroma is a tumor, found mainly in the kidney, composed of adrenal rests, or bits of accessory suprarenal tissue imprisoned within the renal capsule. Their minute structure is often that of the adrenals, with a tendency toward the type of perithelioma. They have hitherto been considered examples of sarcoma of the kidney, but are to be abruptly distinguished from it in most instances. Tumors of this character have also been found within the capsule of the liver and along the spermatic artery. In the kidney the tumor portion is usually distinct from the renal tissue; it is often enclosed within a sort of capsule, and rarely connects with the pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely escapes by the ureter. Hypernephroma is delicate in structure, and its vessels give way readily. After this has happened a true hematoma may result. (See [Plate XXVIII].)
Similar neoplasms form in the adrenals themselves. These tumors vary in degree of malignancy, some of them scarcely deserving the designation malignant. They may be met at any age, but are more common in adult life. Before removal they are not to be differentiated from other tumors of the kidney. Their cells manifest this peculiarity in that they contain a notable percentage of glycogen. It should also be added that even in true sarcoma of the kidney proliferating adrenal elements may be found.