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The connective tissue changes that accompany intestinal Crohn's disease have received little attention from pathologists. This is particularly so with fat hypertrophy, and yet surgeons have long recognized the phenomenon of fat-wrapping in the intestines and used it to delineate the extent of active disease. A consecutive, unselected series of 27 intestinal resections performed on 25 patients for histologically confirmed Crohn's disease was studied to correlate fat-wrapping with other clinicopathological features. Fat-wrapping was identified in 12 of 16 ileal resections and in seven of 11 large bowel resections. It correlated closely with transmural inflammation and there was a relationship between fat-wrapping and other connective tissue changes including fibrosis, muscularization and stricture formation. Morphometry demonstrated that there was true hypertrophy and that fat-wrapping does not relate solely to bowel wall shrinkage. There was correlation with ulceration but in 11 cases macroscopic ulceration extended beyond the fat-wrapping and in six to surgical resection margins. The pathological features of 225 small intestinal resections were reviewed and fat-wrapping was seen only in Crohn's disease. Fat-wrapping correlates best with transmural inflammation and represents part of the connective tissue changes that accompany intestinal Crohn's disease. Findings also suggest that fat-wrapping alone should not be used as an accurate marker of disease extent at the time of surgery.

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Conclusions-Comprehensive pathological analysis of a resection specimen can identify cases with a high probability of local recurrence which may benefit from early adjuvant therapy. Involvement ofthe peritoneal surface is a common event in rectal cancer, has adverse prognostic influence and may be an important factor in local recurrence of upper rectal carcinoma. (J7 Clin Pathol 1995;48:849-855)

SUMMARY Four cases are described in which solitary nodules were identified on the anterior aspect of the liver. These had characteristic histological appearances. Each had a necrotic core surrounded by a dense collar of hyalinised collagen, incorporating elastic fibres. While three of our patients had carcinoma elsewhere none had evidence of tumour in the liver. We do not believe that these lesions represent hepatic metastases. We suggest that they may be of traumatic aetiology or a sequel of previous infection.The identification of hepatic metastases at operation may greatly influence the surgeon in his approach to cancer treatment. It would be important to document the existence of a rare but non-tumorous lesion which might easily be misinterpreted as necrotic tumour by the pathologist on frozen (or indeed, paraffin) section.Over the past four years in our department, we have identified solitary hepatic nodules in two surgical specimens and two necropsies. Their sizes ranged from 5-15 mm in diameter. They were all subcapsular in position on the anterior surface of the liver. Case reports CASE 1A man aged 69 yr presented with left sided cerebral infarction and died ten months later of bronchopneumonia. At necropsy, he was found to have adenocarcinoma of the prostate gland with metastases in the regional lymph nodes and the lumbar vertebral column. A single subcapsular nodule was identified on the anterior surface of the left lobe of the liver. It was white on section, measuring 15 mm in diameter. A thorough search for additional lesions proved fruitless. A man aged 45 yr was admitted with left sided hemiplegia due to subarachnoid haemorrhage. After six weeks in hospital, he suddenly deteriorated and died. Necropsy revealed the cause of death to be pulmonary embolism. A single nodule was found on the anterior surface of the right lobe of the liver.Accepted for publication 14 June 1983 This was white and gritty on section and measured 5 mm in diameter. No evidence of tumour could be found in any organ. CASE 3A 65-year-old woman, who, two years previously, had had an anterior resection of a rectal carcinoma, presented with local recurrence. At operation a solitary nodule was palpated on the anterior surface of the right lobe of the liver. This was sent for frozen section. Slicing revealed a 12 mm well circumscribed lemon-yellow nodule with a narrow white rim.Since this operation eight months ago, the patient has been free of clinical, biochemical and radiological (including CAT scan) evidence of hepatic tumour or local recurrence. CASE 4A 62-year-old man underwent an anterior resection for a Dukes' stage B adenocarcinoma of the colon. During the operation a white 6 millimetre nodule was identified on the anterior aspect of the right lobe of the liver. This was the sole abnormality identifiable in the liver at operation. The patient died of suspected pulmonary embolism five days after the operation and necropsy permission was refused. Material and methodsEach specimen was step sectioned and stained with haematox...

Primary colorectal lymphoma accounts for only about 0.2% of large intestinal malignancies. Management difficulties are compounded by a lack of consistent pathological reporting and by the use of numerous different classifications. Forty-five cases of primary colorectal lymphoma are included in this study. The presenting features are indistinguishable from those of colorectal cancer. Seven patients had a history of chronic ulcerative colitis but no other predisposing factors were identified. Immunohistochemical studies showed that all tumours were of B-cell phenotype. Most tumours were difficult to characterize using standard pathological classifications such as Kiel, except for the 11 cases of malignant (multiple) lymphomatous polyposis, which were morphologically diffuse centrocytic lymphomas. Twenty-nine lymphomas showed the morphological and immunohistochemical features associated with tumours arising in mucosa-associated lymphoid tissue. These tumours showed variable but often marked polymorphism and we have used the term polymorphic B-cell lymphoma to describe them. Consistency was achieved between three observers as to whether these tumours were low or high grade, and grade was found to be prognostically important. A modified Dukes staging system was adopted and there was a trend for early stage to give prognostic advantage. This study supports the view that surgery should be the primary treatment for localized lymphoma of the gastrointestinal tract with radiotherapy and/or chemotherapy for advanced cases and for malignant lymphomatous polyposis.

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Aims-To test the hypothesis that gastric cancer presenting with uncomplicated dyspepsia is rare below the age of 55. Patients and methods-The area studied was the postcode defined catchment area of a district general hospital (Gloucestershire Royal) serving a population of 280 500. An open access endoscopy service has been available in this district for more than 17 years. All cases of gastric cancer during a seven year period (1986-92) were drawn from the local pathology database. The database of the neighbouring hospital and the South West Cancer Registry were searched for missed cases from the postcoded area. Hospital and general practitioner records were retrospectively reviewed with respect to duration of symptoms, and previous consultation and investigation for dyspepsia; and alarming symptoms and signs suggestive of underlying malignancy (unexplained recent weight loss, dysphagia, haematemesis or melaena, anaemia, previous gastric surgery, palpable mass, and perforation). Results-Twenty five of 319 cases of gastric cancer detected during the seven year period were aged less than 55. Twenty four of these 25 patients presented with one or more suspicious symptoms or signs. Only one patient (4%) aged less than 55 presented with uncomplicated dyspepsia. In two patients there was a delay in diagnosis of more than six months after first presenting to the general practitioner. Both these patients had significant symptoms at presentation. Conclusion-Gastric cancer is rare below the age of 55 (7.8% of all cases) and, even in the presence of established open access endoscopy, presents with suspicious symptoms or signs in 96% of cases. The age limit for screening uncomplicated dyspepsia can be raised safely to 55. (Gut 1997; 41: 513-517)