Pulmonary embolism arising from the great saphenous vein

Abstract

evidenced microscopically by the plugging of the majority of the small submucous lymphatics in the stomach, duodenum, and jejunum (Fig. 84). Further along the bowel plugging and permeation of both submucous and subserous lymphatics was a marked feature. Evidently lymph-node and plexus blockage and retrograde spread had occurred. This diffuse lymphatic plugging was doubtless the cause of the terminal ascites.The spread into the anal canal and even beyond it to the skin surrounding the anal orifice is most unusual, but here again evidence of lymphatic permeation, particularly around small nerves, was a feature of the microscopical appearances.Willis (1948) has pointed out that widespread permeation does not necessarily proceed solely from the primary growth, but also from many embolic metastatic foci in lymph-nodes and plexuses, from which further permeation occurs, thus linking numerous areas.The remarkable feature of this particular case is the very extensive invasion of the bowel, with complete absence of demonstrable invasion or metastasis beyond the gastro-intestinal system, its peritoneum, and lymphatic plexuses. Although the perianal skin can hardly be termed part of the gastrointestinal system, yet the spread into it has evidently occurred by direct lymphatic permeation.A question of terminology in association with the spread of this tumour is perhaps worthy of brief mention. Willis (1934) has stressed the abuse of the term ' metastasis ' in many cases when, in fact, direct extension of tumour has occurred. Thus, in the literature of so-called ' metastases ' of the intestines, the majority of cases are examples of direct spread. Willis (1931) has pointed out how very rare true intestinal metastases are.In the case here described, much of the extension of the tumour is by direct spread, but if the theory of lymphatic-node or plexus blockage with subsequent permeation is to be accepted, then a certain degree of true metastatic spread has also taken place, and the changes might be properly described as carcinoma of the stomach spreading directly by submucous lymphatic permeation and metastasizing to local serous lymph-nodes and lymph-plexuses, from which further direct spread by permeation has taken place.The exact designation of carcinoma type in this case gives rise to some difficulty. The stomach tumour, particularly in the pyloric region, suggests a colloid type, whereas the intense fibrosis both in the stomach, but more particularly in the rest of the bowel, seems to suggest ' linitis plastica ' as a more apt title. Ewing's ' diffuse scirrhous carcinoma ' seems the best description, but this case certainly upholds the dictum of Stout (1943), repeated by Willis (19481, that there is no value in attaching " histologically descriptive adjectives and prefixes to gastric carcinoma ". S U M W R Y I. A case of diffuse scirrhous carcinoma of the stomach with spread exclusively to the remainder of the bowel and perianal skin is described, together with a brief review of the literature.2. The unusual clinical histo...