J - Rosai`s Collection of Surgical Pathology Seminars

Transcription

TIJMOR SEMINAR COLLECTION
SET XXIII _
Twnor Seminar, Columbia,
•
1949, Otto Se.phir
<ll:olumbia Ulnibersitp
~oUege of .tlfJp5icians anb $urgeons
630 WEST 169nl STR EET
N ! W YORt< 3 2, N . Y.
D E PART MENT OF SURGERY
SU RG ICAl... P ATHO L OG't'
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:; :·. :1i ~:1n:\.• : . ~t ;"'IJ \rtr.("\'1 •
!:lEn l"L ·hcl ::;··· •._ ;;."tc"'r
C:l~...·~bia, ":.rr-curi
_.I
Oct"lx>rl7 , l)~~·
~osrital
':'h~,.,J~ J·ou very much for senJins me the Seminar sli des .
I r.<n·e brocn over all nf thorn on1 am ;;cn"ing you copi£'s of cy dioc-sdr,.. ~r £nch .;~~t~ . I think it would be bt'tter not to introJuco
rr.y opinion:: in t o t.J-e Semi~ar . ;:,ake what ver use ~·ou ca-:-c to <'f
;:.c:-:J .::e .... :.tis oYer b\:.t, it might be embarraooine f or Dr . Sarhir
tc have r.~- opinicns i:lj ~::cted in to his Seminar . I sba} 1 be rJuch
i.."lte''C. "te j t" l·~.:.r .• ~lis diP.:;:1o~c o and interpretations, a:> we11
as t.,Lo~c o f al: ti,c x·es t of you . I thoue!lt the bt'€'as t ca:>eo were
~-. rtic'l) 1:-l:' int.Grcc." i n-: , a :1l difficult.
SincercJ.y yours ,
J, rthur Pur-ly Stout. ,
ArS :KE •
I ) ,,.
I
?' . ;) •
~ o Urge
of l)bpsicians anb §burgtonS'
SURGICAL PATHOLOGY LA BORATORY
Continuation Sheet
TU!lO SOIIUAR - Oct. 22 , 1949
'l'l'xl L.111B Fischel Zt..' lto C.ancar Hospital
Col 'Uf.lbia , f'1aaour1
r.c!'lluct:e:.! btJ - Dr . ot to ~aphir.
C.\SE 1 .
~'all,;nant ·~clanoo.a
( ?) of Axillar/ Lymph nland
o! Unknown Or igin.
lJI CROSC.•?I C*
The 1:1'-l?h node 1s 1llfilt ratod by r roupa and corde ot
t 1.1t1or ct~l la of v" ry lar;·o aize with one or !!\Ore la!'r.e nuclei b\1arin!! largo
nucleoli . Hany o~ the cells have ptJucocyte..! Dmallor cells . lt.out of the
<.'1:' 11 s
a !'O :n s inuses .
lJo
~lifror:•tmtiatin;;
characteristics are i <ientitie.j.
OI :iC:.!- I CJl! 1
Obviouo\1 this i a 11 mtastot.1c carcina-..a anJ Dince
nc ;:>t'imary focus TlaO Jls~r vorod at autopsy wo rema .n bat'tleJ by it. .
The only :ru 1·;-eat1on I can m.al<e io tllo.t ootaotae1a like t hio haVfil como
in othl ::- caaos !.'roo primary gient cell carcinomas of the lunr . I do
::.ot bcliovL t hc oe are - '- t astatic bopatoca cella nor !'ro::1 t~ t!:yuua,
bot of ~ioh or,.nna a re capable of proJucinn cells or giant abe .
The> ro is finally t.t:u oH mt andby for 1ootastasoa or an epithelial
nature fro... a •1 undiscovort.i sito and I prosumo it !4\lDt be invoked
1n t.l.is t· :.so , na.-:JOl:r tho occult un;;liscovered aaligno.nt m lano::.a.
h rthur Purdy Stout,
. ..
.....
.
I(.D.
Qi:ollrge of .Jlbpsicians nnb ii>urgtons
SURGICAL PATHOLOGY LABORATORY
Continuation Sheet
Turuor ~ e mi.nar - October 22 , 19L9
Lllis Fi 9chel ... tate Cance r liosp.,
Ccl uu\J1a 1
V 1~>uour1
co~:h:.ctoo.
b:,r ;)r . iJ t to 5e.pb.1r .
CASE
2
DL\~::oors :
I ntraee.na.11culor Fibroadenooo ( .~ultiple)
or r'or.'llal.o l:ac::m.ey r.laud.
'ti CB)ZCOPIC:
i here a rc
thNlil
circl.lmScribed nodules 1n w>jich ducts have
pro~ iferlltf: J Pn l t heir 'l'llllls have been 1nvar;1nated by fibl"'UB tissue pro, iferation 1n such a \'8Y o.o to wake i t a ppce.r :ln pl a ces as i f papillary
in tra·luctal growths ha1 formed . : ['he otro:oo. 1cJ fibl'OU!l a nJ dOes not a ppear
sarccoatoWJ . Tho epithelial cells OOI'Ihere seeo on&?last1c or llko ca..'''lcer
cella.
J I !>VUr. I Cl'h
ThiR ecci:lS t o me to be one of the f orms of proliferation
th£ br t:aet due probably to DOroe varifJty of hormonal etimu.l ation in
which rrowth Ui.l{es on th9 aa;:ec t of intracena11aula.r f lbroalienoma. I t
i9 OOI!II.:i!hat -..~..m.:sua:! to enco~mtf:r it a t abe SS, but I ha~ ooen i t in a
in
wanan of 70. 'rl:x: hiotory of nipple dioche.rt~ is int.crestirlK but T do
not tJ1ink i t M oo explni uod by the uppearance or these ne>Jul.es . Judgin.· ~ :·o.;; t.'1 r ross Jscri ptlon the ope ator had a ho.rJ tim to l ocate t h1a
no.:l,ll C'J il'l j exci t:oJ a lot or breast. t i ooue look1nr for e. em cer.
,
...,
QCoUrge of f)b!J!licianjj anb ~urgtons
Continuation Sheet
Tu;or Seminsr - Oct. 22, 1949
F.ll1e F1oche1 S t a te Cancor . ' onp.,
Columbia , • i~r.ouri
c oniucttJJ by r. tto Saphtr .
OL'i2lO:JIS a
Papillai"'J Carcinoma of Female Uarnmary Oland.
!IT::aroco PI C:
·rt.c brce.ot
t.i tHJo.:c
outoide of the noJule
ahom~
b w:lch t he i ntr a 1uctnl cpitheliur:J ha s proliferate.! to
somo ducta
form cribrii'o:rm
and ~pillary r atttJ r ne .,rlt hio the d ilaw d lumano. The principle l eaion
ia a com~lex ;.·aplllary tw.1or in w'11ch the compounl stalks or fibrovas cular
t.is~ue a re c.loU.cd -:it~ t a l'l. col~;m!lllr celle wlt.h lar.: e n uclo1 but no j1rominent nucle oli an1 a mo-Jorate m:n:ber of mitoses . The t umor is aharplj• oir CUI.:Scribej anJ does not. s he'll true i nfiltration o1 thoUt-:h i n l!l coo pl.acoa
injury m :i flbN is ha s reeulteJ i n t'lnclc s1nt~ n few t \mior nle.n"ls i.~.11ately
benea t b t he 11n1np . The t urnor c ella d o not sh<nr any cyoopi thelial tails.
nr:.r.u"Si f'llh
T~is is au cxceed1nnl y 'lntcrestin,... t umor whi rl'l f or:ncrly
I u~e J t..' t hin!- l"faS benir,n but ! n01t consider it a repill &t"J carotnoma.
The c~:~ lls &ltlwuch quite reRular are different from any of too cells which
haw pr oliferatej 1n t!'.e ou1.side ducts; they show mitotic activity and the
history in.ii catea t hat t re tuoor has bt·en gfotdng. 1i'hat. has c onvinced oo
that a r.rcrnth 11J.:e t.his i s a carcinoma 18 i to C8P4bil1ty of motastas1a .
I ci o not believe such papillary c.D.rcinomae arise frOt.~ pre-oxisUng boni &:n
int.ra<iuctal papillomas; at l east I · know of no ,:lofin1ttl pl'oof that tlwy do
so. Tlloy arc vor ; unCO'.JOOn an•! as in t hio case arise at a d istance from
t-~o nipplt. sone .
They a re SCXGt:'\11-. at canpara\>lo to the carcinoma in e i tu
fot'!:l.>t.i ons in otlwr or;::a.no anJ a re ve r-J raro . t'otastaais 1e unCOQmon
but oon oib~o .
Arthur ?ur.zy Stout,
L1. n.
~ollege
of llbpsitians anb ~urgeons
SU~GIC;\L
PATHOLOGY. LABORATORY
Conrinuatioo Sheet
Tun1or Seminar - Oct. 22, 1949
Ellia ;;is ctcl ; ....aw -:ancer Hoep.,
Colurn~ia , I i~ souri
Conl uctod by ~l r. Ctto ·:n'P~1ir .
CJ,SE
4
PopillL'T'J Corcinooa of fo'e.lllalo t.!c.rlf.14U'y Gland .
"l ": r.G~~~:
I rresumo these qectionn cor.o from tho t \TO leibc -:yeta
nention.ed :.n the breast and that the roet of the ma:;nr.ur 'J tiSSU{) 1:~ not
sh~m . The ~o:<~t in t his case is swr...,.Jbllt comparabl e to tl'>.at seen in
Case 3. but <Jiffer~: bccauae of t he r.ru.oh greater acl.Ount of tur.:or call
pl·nlifarati on i:ll'li itc ~olilf:t'h at:. C:lfferent chr.raote:r . J.n t!)!a 1:l:l.Be t."lere ia
SCTro pr vli:'er.:Jtion of t all colum11ar cel ls but <'Onaiots chiefly or v.asoes
of roun..iod cells vt:Jich ar·o f<>wld :in oo11J form&tione in the papill4\e
sw'tllount vd somet .oos tr.r· the columnar cells. L1itoses are very rarely
s een. Tl!"re a.!"e many paaL:Doma bodies . There is no good f:IVldence of
infilt-ra tion intc t,he <'yat. walls.
I believe t;,ia is another e:>..'lllllple of papillcry
carcJ..nCJaw. and ! n.n SU!'e t hu t oc-100 lrl.ll interpret th ~ s picture ao
evHence cf th v J eve1orent of a carcinoma fr001 a be:1ign papilloma.
•r ••io rr.ay be 1:10 l:;ut ' a ·J ver:; hE::ait».nt. to accep t ~uch picture:; as thits
~s proof of t..~1.1t ·nter·pro;t... tlon witi.out f ur ther ccni'ir'JlUI.tcry evidence.
I suspec t t.•mt 'r.n oth~J r r.~<~rtt; r. f. t i·i!l tm.• ast there nay hevc bt:on foun j
evi-:lence of "in!'ilt-rat:l vc r:; r.onth . r.nd perhaps a..--dllary 1ac tastaais but
DIS CU~SI011 a
I woulJ not
~JO tGo
astoni:.>ho:l 1( t his was not the case for tt¥.:ae
AS a class a 1-e :~J m~r to rootaate.size run thet-efore
.Jore c;urable b;; radica l !51st,:.ct o..ty Ula."l tl:ic avc raev breast can:er. In
an~· e vo nt , ' w liave tJ1at no attempt shoulol be oade to a pply flhatover
Lntcrpretationu L1ll}' be uinde or thtJsc two caoes t o the co.:u.on intratlu.ctal papi :1 owao of the nipple zone . Thoy a rc c:artainly not any ruore
prccancerou:; tr..an are t !;li ti ::~oucs of the average woman•s breast.
papill ary c<U·cinonas
Arthur 'f'Ur..i_v :> tout ,
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7 !:.!.3 1 !1 t.•1t . Sa:Je ca!)() .1s 11aa acnt t o· .Je previmwly b,; ';}r. '~nbson . A
ccpy of cy .les cr lrot lfln a,'11 t!1 scu::.s :..:. at th~t. t !..n.e !.s or.~ndoJ. The
diamc•si.s r,f !-.seu.-rcn co of c;rstosu··::c..l:a p::yllolos in th.. for.. of a. fibrosa ...·ro..-:r .:1.,,- 00 c -·l""·"''ct. J f' rvv:-· U·c=; t"'\"i 1onro T r~tl'1.-:"t btJ flU!~ .
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p:-0r:u'f.c.! ·TJ. t:· o.sscm ' .... ::r !.chr"'ne susin. .
Thr;;.>· ars lab.!U l n<J fc\J.cllS: h7- n ::h n!Jmd .n: t.;ut:or. L7-~)$'{ al",o-r;i ng no
tx..o~· , ~!'Q:!. fl-3 ', C!~• r:• t.i.On J 1)}-.')11?'2 t ;·p :Jlif'lmJ !'rCX'l t,ll-.o~r~.·r.)rld 0-per. ,t.im ,
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(ctnt.in:.:tJd)
~oUe!Je
of
~b!?.Sicians
anb 35>urgeons
SURGICAL PATHO LO GY LAI30RAT O RY
Co ncinHnrio o Shcc:t
PW 31301
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SURGJCAl.l'AT H Ol.OGY LABOR ATORY
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SURGICAL PATHOLOGY LABORAT ORY
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ahor.~ h :.2nrrc a~:,rpii"All pl as::.a co n for ::.s .
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CASE
15
'rhyr o1o:ttis
( t ype? )
(.'(l().;.:;c··rc :
ThG t .;yr,:)li i a the seat of an £:.Xwne1ve pre, ces s which
illV0l V0.J a ll of tht~ ti St:O i n t hr.: :J(,Ction . 'l'here ill a groa t .leal or
fibrosis .a:11 t ho n• .~ainill · thyro1 ! f {.J l1iclea of ten :io not lluvo any l ll.!Den
but a.ro r c proo€nt.G.1 by inconspicuous solij balls cf ce lls . 'lllc t hyroid
l obule s are exa -, e:rate:l. 'vi connect i ve ti!. aue which sor.•e ti::.cs wo t.a.U1 a
l et of 1;.-m;,hcl t t !.s::n:o i.t1 t.he aharx of lar~"G follicle. s .
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::c·:c·n .i ques tio!1 tlJio thyrrJ:J.d is t,t-.c :Jetlt of a verj
sxteneivc: ·::.~ yr C'i l i t is b.i chli;:.htod t;ot !J b.Y !lhroal e and l .;r,..;>l.oid i.:lfiltrs.t ion ootJ·, i n :-o~ liclea U'\d as ::rL'lGJ.(; cel ls . The qut\:>tioh , ! :;ap· osc,
ic o:: bott.er O!' :10-'.. t t ;.(;l'C i s arzy evidence or cancer. : f'.r:Olo:o U€ttcr t han
to Lo Jo~:-'d t,ic acout t-ho t :ij'l"Oid but I w11:: BB.J' that .,.. a ::. u <:~ble to
-acorn::. zc- a:1'.f <.:vi .len co c .. d can ~rous procos!'l a.r~'n t' t i·,,; u pi tl!e lial cello.
This ca!.>e !ONJ not ec(J::; tc r.~ o:Y.act l :r ~ !'!.t ! nto t~lo nwx;i cl as f~s of
t
;:,~·oi.li ti s •
•
; rtl·.ur 1"Ud,y Stuu t,
.n.
CLINICAL PATHOLOGIC CONFERENCE
Ellis Fischel State Cancer Hospital
By
OTTO SAPHIR, M.D.
CHICAGO
Reprinted from
The Journal of the Missouri State Medical Association
Janum·y, 1951, pages 45-54
Fcbrunry, 1951, pages 125·132
Morch, 1951, pages 191-196
April, 1951, pages 297·300
•
COJlJ!ri0/11, 1051. bu Ml,.ottrl St11tu Mod! cat Maqcl«tloll
Ellis Fischel State Cancer Hospital
OTTO SAPHIR, M.D., Chic!lflo
called it. Fortunately, I t•eceived sections of various
organs removed at the time of the autopsy. During·
the preliminary examination of the body, the pa·
flistOl'!/.- {Presented by Richard E. J ohnson, thologlst noted that there were numerous firm
M.D., Ellis Fischel State Cancer Hospital, Colum- areas in the breast. These were of irregular distribubia). The illness of this 26 year old white woman tion. One area, however, was distinctive in that H
begmt fout· months prior to death when she noticed was larger and conformed to the definition of a
enlat•gement of the gla,nds on the r ight side of her tumo1·. May I read to you what I wrote after studyneck. This was associated with aching pain involving the slides? "From the microscopic sections of
ing the neck, right ann and right thorax. Some all the tissues; lt seems clear that this is a primary
swelling of the arm developed subsequently. A carcinoma of the breast with metastases in the lung
hiopsy of a neck node at an osteopathic hospital was and, among a number of other oxgans, also in the
Interpreted as "adenolymphocarcinoma ." She re- ovary.' A t first, it seems to be a diffusely infiltrating
ceived an indeLet·minate 11mount of x-ray then1py, cat·cinoma, apparently arising in the small ducts of
with slJght improvement. Two months prior to the breast," as was seen in the ·photomicrographs.
"A more detailed exam.ination, however, reveals
admis~ion to the Ellis Fischel State Cancer Hospital
she developed headaches which became progres- that sdme of the individual carcinoma cells have t·e·
sively more severe and two weeks prior to death, t.ajned the ability of producing a substance, identinausea, vomiting and photophobia appeared. She fied as mucin by special stain. In the lymph nodes
was admitted to the hospital o.n June 8, 1949, in a these tumor cells are large and the ttuclei are pushed
stuporous state. Exam ination revealed signs of in· toward the periphery of the cells producing a signetcreased intt·acranial pressure. There were enlarged, ring cell appearance. In other words, it is a prifirm lymph nodes on both sides of the neck, and a mary carcinoma of the breast, mucin secreting,
Single discrete node In the 1·ight axilla. The la tter which had ..Produced metastases."
This case is interesting in tha t this patient was
was excised. Her condition deteriorated l'apidly
and she expired on June 19, 1949.. No primary tumor
was evel· idetttified. There were no significant labomtory or x-ray findings. An autopsy was perfanned.
The section is from the discrete node in the right
axillu.
Primary Mucinous Carcinoma With Signet
Ring Shaped Tumor Cells of the B t·east
DISCUSSION
OTTo SAPHm, M.D., Chicago: In this section of a
lymph node {fig. 1) there is indisputable evidence
of metnstatic spread of carcinoma by way of the
lymphatics. Carcinoma cells fill the subcapsular,
cortical and medullary sinuses. In other areas of the
lymph node, extension beyond the sinuses is evi dent with the formation of sheets and cords of tumor cells. The cells are polyhedral or spheroidal
with a fainlly acidophilic 01· basophilic cytoplasm
which is generally gr~:~nular. However, in many
·areas it·contains vacuoles of varying size. Some of
these are large with J'esultant compression o·f the
pet·iphemlly d.isposed hyperchrolT\atic nuclei forming the "signet-ring" ce!J..The nuclei are sometimes
exceedingly large and pleomorphic. Many tumor
giant cells 1\l'e seen. The chromatin is finely reticulated with focal thicl<enings at the points of intersection of the fibrils. The nucleoli are usually from
one to three in number, large and well defined.
Atypical. mitoses are numerous.
This is an unusual case. If I had seen only the lymph node I do not know what I would have
'
1'rom lhe 1950 'l'umo< Seminar held ot u,. Ellis Fischel Stote
Cancer lrospllal, Columbia, conducted by Otto Saphk, M.D.,
Cblcago.
Fl~. 1. ~1etnstasls to lymph node. Note n tow • lgnet·rlng
t umor cells.
only 26 years old and the presence of a carcinoma
of the breast was not suspected cllnlcally.
The circumspection of the pathologist in this case
is highly commendable. I£ he had been less prudent,
he, too, might have failed to find the primary site.
I cannot overemphasize the fact that pathologists
should conduct a careful external examination at
the time of autopsy, and it is of greater significance
that the importance of this particular concept be
conveyed to th.e clinkian. It has been my experiepee, and I am ce1·tain that of others, that a clinically unsuspected carcinoma of the breast found at
autopsy creates much chagrin to the clinician. It is
deplorable that in this day and age when everyone
is "cancer conscious," a carcinoma is overlooked in
such an accessably palpable organ.
Some time ago I was a wit.ness to such an omis·
sion. The patient, a 60 year old female, was brought
to the hospital with the diagnosis of a myocardial
infarct of the anterolateral wnll of the left ventdclc.
The lotte•· was confirmed by electrocardiogram. The
patie.nt expired and the cause of death, clinically,
was believed to be due to the myocardial ittfarcllon.
AL autopsy, palpation of the breasts cliRclosed tho
pt·esence of a primary carcinoma. There were extensive metastases as well. The physician, a cardiolo·
glst, defended his omiss ion at the clin ico-pathologic
conference, in the p1·esence of n large audience, with
the following statement: "Well, we are not in the
habit of palpating the breasts in evet•y patient witlt
myocat·diul failut·c. Our patients would not like it."
I consider this a deplorable attitude and welcome
th is opportunity to express my p ersonal opinion.
In these days of specialization. one should not fnil
to remember the necessity of a systematic and
thorough physical examination.
Comi ng back to this case, thls typo of carcinomn
belongs in the group of mucin secreting or mucinous
carcinoma of the breast. In my opinion, there at·e
three dlllerent types of mucinous carcinoma o£ the
breast. ' The firs~ type is a mucinous cm·cinoma in·
volving the finer ducts with the production of a
large amount of mucin and, ultimately, pressure
att·ophy of the duct sll·uciures. If this is complete,
recognizable cells wiU be absent and one will see
only large cavities or large circumscribed cystic
structut·cs filled witlt mucin. This is the true mu·
cinous adenocarcinoma. The concept that mucinous
adenoc;u·cinoma is usually relatively benign is based
upon this l-ype.
The second type is not a true mucinous adeno·
carcinoma, but primarily a duct carcinoma in which
lhe individual cells produce mucin. In some miet·oscopic fields one mny see st•·uctures which are chllt'·
acteristic of a duct carcinoma, while in adjacent
areas are structut·es resembllng those whiclt I have
descl'ibed in the first type. This ls a duct carcinoma
with mucinO\lS features and its biologi c behavior is
similar to that of a primary carcinoma a.-ising from
the ducts of the breast..
Th e thit·d type, the signet·t·ing cell type of mu·
cinous adenocarcinoma, resembles the case under
discussion. It is characterized, microscopically, by
well preserved, mucin sec•·oilng cells with baso·
philic o•· clear cytoplasm and crescent shaped compressed nuclei. Appflrently, these cells become isolated from the ducts and acini, Invade the stroma,
nnd p roduce widespread metastases. Morphologically, this type resembles the so-called linitis plasti·
ca type o( earcinomn of the stomach. Both contain
individual tumor cells whi ch p1·oduco mucin and a
large amount of connective tissue. This is one o£ the
most malignant tumors of the breast. It produces
widesp1·ead metastases. Almost invariably the bon~s
<H'e involved and often there are metastases t~lte
ovary.::
It Is lntoresUng that, occasionally, such a meta·
static ovarian carcinoma (often called a Kruken·
berg ca rcinoma) dominates the clinical pictul·e, sim·
ulating a primary carcinoma and for which an
oophorectomy, or most likely a panhysterectomy, is
performed. In nearly every instance the primary
caJ·clnoma is in the stomach ; occasionll lly, however,
as in this case, the primary carcinoma may be in the
breast.
The •·e 11re a numbet· of intet·esting changes in the
lungs. There are not only mestastascs but also lu·
mor emboli in the pulmonary vessels. The latter
also show definite compression by young granuln·
lion tissue which, 1 think. is obv iously the result
of organization of tluombi caused by the tumor
emboli.~
This case is an example of a diffusely infiltrating
signet· t·ing cell type of mucinous adenocarcinoma
of the breast with metastases throughout the body
and pot·tlcularly in the OVl11'Y· These iumors should
iiot be called gelatinous carcinomas because they
do not produce gelatin. They are not mucoid tu·
mors because they produce mucin and not mucoid.
They certainly at·o not colloid ca rcinomus. Only two
organs produce colloid-the thyroid and the hypo·
pbysis.
LAUREN V. ACKERMAN, M.D., St. Louis: In my
opinion, this is, an unusua l variant of breast car·
cinoma. I wonder If you might make some statement
as lo the frequency of this type of tumor? Would
you designate it os a signct·t·ing type or mucinous
carcinoma of the breast? Would you say they all
had a hopeless outlook?
Dn. SAPJliR: In the first place, this is a rare type
of cat·cinoma of the breast. perhaps among the
rarest types. Several yeal'S ago a study was con·
ductecl with J·egtH·d to metnstases flnd it was found
that the ovaries were involved in seven ou t of
forty-three cases of primary carcinoma of the
breast. In add ition, about six cases in the sel'ics of
forty-three, if I remember correctly, were primary
carcinomas of this type. This study made us cog·
ni2ant of the significance of ovarian metastases, so
much so, that now in the presence of signet-ring
type of mucinous adenocarcinoma of the breast, we
ask the clinician to palpate the ovaries, and often
they reply that there is an enlarged ova ry.
Morphologically, this type of carcinoma is iden·
tical with that seen in the stomach. Therefore, ns
far as nomenclature is concerned, one may cull
it eithet· a diA'us<!ly infiltrating ca rcinoma of the
linitis plastica ty pe or, better, a mucin secreting
adenocarcinoma with signet-ring tumor celts.
Dn. ACI(ERMAN: l have seen the same type in the
large bowel and it had about the same prognosispoor.
Dn. SAPHm: At the present we are studying three
carcinomas of the colon of the same type with me·
tastases to the ovary. Did your cases also hnve
metastases to the ovar y?
Dn. ACKEilMAN: I cannot recall whether it did
or not.
JACK H. HILL, M.D., Kansas City: We had a cusc
of this type in which there wet·e unusual bone le·
CLINICAL PATHOLOGIC COm' ERENC&
•ion• consisting of smaU, hard nodules throughout
ihe cancellous portions. Do you have any knowl<dge ol unusual bone manifestations?
0.. SAPH1R: No. I do not remember. It would be
very instructive to dctcnnine whether an osteoblasllc type ol lesion, or a n osteoclastic type of
mcla.'ilnsis, is produced. From your descriptio n i t
socmcd nn osteoblastic type. D id you classify the
melnstnscs of YQUr case as an ost.eoblustlc type oi
mctnstruds?
On. liiLL: Yes. Our patient d i<'d n iter an op eration. The p rima ry s ite h ad n ot been discovered
clinically. At a u topsy there were n few smaU nodules in the stomach. 1 to 2 mm. in diameter. bu t
no primury tumor was identified. We WCI"C amazed
to find that the tumor cells in the stomach were
identical with t.h ose found in the cancellous portion
orthc hones.
MARTrJ< Su.ne• •••c, M.D., St. L<>uls: What abou t
the multinucleated g iant cells p•·cscnl in tl1is tu·
mo1·?
DR. SA.'Ptu u: Yes, there were some giont cells but
I did noL think thal t hey we1·c ptll'ticulnl'ly ch aractcrisllc. In uny case of carcinomo one anay occ asiot~
ally sec giant cells.
DR. Su.eow.ERc: I was conce1'11cd with the sign!Jieanee o! their association with this unusual type
ol cardnoma.
DR. SAI'IUR: I do not know if there is any sig-
I had to do It over again, I am sure J wou ld make
a n\ist.akc.
DR. SAPrnR: I sympatlilie with you because I think
1 wou ld make the same mistak e. It is important to
kno,v nol only the histologic p icture, but also to
know th e origin o r the lesion. [n o ther words. on~
must. b(! cq uipp(!d with an adequa te dl fTcrcnLial
dJugnosis. 1n t his p a tUcul ar case, one wou ld ha ve
to l'U le o ut n lesion i,n- the nasophAr y mc 01', pcl'hr.ps,
a, br o nch ogenic carcinoma. Assured ly, t he miet'r.;l ·
scopi c nt,pcornnce a lone would not wtu·•·unt. u d iug\
(
Ff%. 2. lntrnc-,yslic; poa:pillo[J'IO) (fibrop,1plllom;a).
nlficsnee.
M.D., St. Louis: t would like
to ask il the pictw·e in U>e l ung was anything
like tha t ollymph angitic car cinoma? We huve had
two cnscs with widely d isb·ibuted mucoid cells in
the lung. The primar y lesions were dUllc:ult to fmd.
In on~ t.he primary lesion was in the stomach. Were
the metastases all in the blood vessels or were
1here any lymphangitic metastases?
DR. SAPHm: There were quite a lew lymph vessels
involved, particularly peribronchial and perivas·
cular.
fle><RY PLNKERTON,
DR. JOHNSON: Dyspnea w as pro minent in this
patient.
M, D. WHEELOCK, M .D ., C hicago: t wonde r hov.t
many indiv id ua ls would s tUJ m a ke
fl
diQgnosis of
nosis o f ca•·cinoma of the b1·east if oil the !aets
of the c>'.• e we re not available.
E. D. S uGARllAKER, M.D., Jefferson City: 1 t hink
jt is imp or hm t to note the clin ical histol'y of this
patie.n t a nd the extremely short cour se of her dis·
ease which wns p robably prematu rely tennbmted
b y a brain metastasis. It is p roba bly fai r to state.
in answer 1<> the question ask ed by Dr. Hill, that if
brain met.1stasis had not occurred, it seems quite
likely thnl this patient would have gone through
the gamut U!lunUy seen in young women with skeletal m eta.st.1ses.
1 S~J)h ir o .: Mvc:iuou5 Cartmoma of U1c Urta1t. S\.lrl£l.
6 b11t . 't:: .008-0H, l u-41.
.a. Snphlr, o.: '!11v fo tc of Carcmoma
Am J . Pn111. ;.~a :-24!1·253. l!H7.
Cync~.
&
2 S(tphJr, o .• nnd P:u;·kcr, :o.r. L.: Mt.:ltl$tnsl• or. Pr ltnary
c o.rcln.oml'l ot lhet Breast. Arch. s.urg •12 :lOO!l~ Hn~ t !NJ.
cnr cinoma of the bre·1st from lhut pNrticuPrimary
'
•
·
._
c •
EmiJott in 1 he Lon2.
Jar lymph node? I do not be.lieve 1 would do i t again.
I hovG beCJl quite lu cky in mllkina 0 d ia.gn osis oi f.,, IJtl r RC\'Kiie Fihropa! '!Joma or the B reast
carcmomo of the breast, metastat ic I<> the lymph
I»•Ueii'~<I.ICUU>,Il. p (!, ~l>E~OI• Jl
1
noc!o. despite the absence of a palpable breast nodHistory. -(Prcsented y Otto Saphir, M.D.. Michal!!. The cells, of co~. w ere much more charac- ael Reese HospilaJ, Chicago). The patient, a 55 year
" listie than in this case.
old wh.i te woman, entered the hospital because of a
It has been my good fortune, due to the courtesy lump in the left breast which she had noticed three
oi Dr. Gardner of Northweste rn Unh•ersHy, to see mont hs prior to admission. It had grown gradually,
sections of ovarian tumors sent to gyn ecologists increasina to t hree times its original site. There
who were interested, primarily, in o v:arian tumors. h ad b ee n n slight amount of nippl~ di.sehru·gc and
[ hnvo been impressed with th~ fact t hnt tn every set ach in g in t he breast. Th~ fa m iJy ·history wns •~ot
- which comprises about ten to t wenty sUdcs- signjfica n t. On physical c.xami nat.lon the lcfl l:n·crH;t
there Or(! nt least on e C,)l' two ovarinn rnctnst.ascs, tllC was s ligh tly lnt'SC!l' than the r·ight. A nOI'I tondcl', we))
1nimtuy lesion being in tl1c breast. They were not
cir cumse1·ibcd, freely movabl~ sofl n odu le mt:Hs·
muein secreting or. if they wer e, they did n ot hav e uring ~by 2 em. was felt in the outc-t· lower quad th~ eharaeteristics such as you described her·e . I rant of the left brcasl The overlying skin was
r.annot conceive of the histologic characteristics. li fl"eely movable and there -,.vas no ~traction o£ the
CLINICAL PATHOWGIC CONFERENCE
nipple. Several shotty firm lymph nodes we~ present in the right axilla. The lumo.r was removed.
The specimen consisted of three irregular pieces
of brcnst tissue measuring 8 by 3 em., 5 by 4 em.,
and 3 by 3 em., tespcctivoly. ln U1e smaller piece
the1·e wns o firm, well circumscribed, bulging, somewhat granular nodule. Sections through the other
pieces revealed gleaming white surfaces in which
an occnsion.al small cyst WIIS noted.
DJSCOSSlON
OTTO SAPHffi, M.D., Chicugo: In tl1i• section of
the brcnst (fig. 2) , which is the seat of extensive
fibrosis, focal hyalinization and calcification, there
are numc.rou& cysts,_ some or which contain a hom o-
tion of, connective tissue. these lesions usually can
be palJ)<lted clinica.lly. or the J)<lpillomas or the
breasL this ty-pe, in my opinion, is the most fre-
Among fifty-one papilloma~ which I have
pcrsonolly st udied. nbout (ot·ty·two were l'epresentaUvc o f this type. I
qu~nt.
Pictures of this particular case show n cyst into
whieh projects this mass or connective tissue C::OV·
ered by the duct or cyst lining cells. Now, one can
easily Imagine that if mol'e connective tissue wera
present in this region, lhen these two poplllae
would llpproximate each othe1· and s imulate u.n in-
t.t·acnnoliculal' fibroadenoma. This pict ure also 11lush-atcs 1he ingrowth of papillae into the cysts.
The paucity of nuclei In the papillae is cvldenL I
repent that lbe papillae are broad; that this is a
Jibropapllloma of the breast. a benign lesion, which
geneous. deeply eosinophiUc material. The lining
epithelium is low cuboidal and arranged In two
layers. Tho pct·iacinar connccLive tissue is inc1·cas.W may be multiple but does not require either n simple
in thickncsl'.i :.u1d projects into the cysts clovnting or radical mastectomy.
the lining cpithclium with Lhc formation or vaJ·iHxNNY PINKERTONJ M .D .. St. Louis: It sccn'IS to me
form excrescences. Due to the close proxinllty of that in o good many cases of chronic cystic rnastJtis,
some of these, the opposing layers of ephithellum one can see this change in a minor dea~. On~
simulate glnndular structures. At times direct con· will sec small intraductile J)<lpillomas and small
tinuily with the nmin lumen is not apparent. Tbe miet·oscopic: adenofibromas. I wonder if this is mere.
celJs AI'C uniform ancl there is no extension beyond Jy an cxnggcration of that. 1 wonder if there is ~:my
the basement membrane.
reul bfl$ic dHicrence between t.hjs and ctu·onic cys·
My dlugnosis is an lntrocystic papilloma of Lhe tic mastitis?
fibrous type. the complete diagnosis being int r aDa. SAPKlR: You arc quite right. In tl1c Jll'Oamble
cystic fibropapilloma ol the breast. As a preamble I d,slined my terms and swtcd that the le.•ions may
to the discussion of the next three cases. I would ' occur nlone or in a breast. the seat of chronic cystic
like to emphasize thai J)<lplllary tumor$ of the mastitis. Clinically, they appear as well circumbreast must be divided Into two groups. In the
first, tho pnplllary excrcsences are part o( a more scribed tumors. There is no doubt but tha t any typo;
of papUloma may occasionnlly occur in K bl'Cnst \\.tlt.lL
gene1·ali~cd disease o r lhc breast, such as Schimdiffu
se disease .
melbuseh 's disease, or cystUcrous hyperplnsia, or
Lr.o LoWBEER, M.D., Tulsa, Okla.: Would not the
chronic cystic mastitis, Ol' whatever one may ehoose
to call it. In lbc second group the J)<lpillary tumors age of this particular patient \vho was 65 years old
constitute lhe principal lesion and are not. associated rather exclude the possibillty or a diffuse process
with any oLhcr major disease of the breast The. such as fi.brocystic disease: which, in my experience,
fo.llowing cases ru·e examples of the latter type on ly. invariably occurs. at nn cm·liet· age?
This cose i~ an int racystic papilloma of t he bt·east.
Dn. SAJ'IIl11: o'ibrocystlc disease may be fo und in
Although there "vas a dischtu·ge from the nipple~ the older age groups but begins more often in l.he
there was no bleeding. Tho outstanding histologic
younger age groups.
findings a.re the dilatation of the ducts \\~th formaHlLLWID CoBL'1, M.D.. Kan= City, Mo. : Dr.
tion of eysts and the presence within these cysts or
Saphir,
might not a fibroadenoma undergo cystic
a connective tissue stalk, ot· •everal stalks, covet·ed
by dueL cplthellum. Sometimes two adjacent o r op- changC11 and simulate a picture like lhls?
DR. 5APmn: Yes, it m ight, but then one would
·p osing stalks, each surrounded by epith ~l hun , a1·e
in closa npproximaUon. The two t•ows of oppos5ng also expect degeneration ot the lining epithelium
lining cells may partially fuse and 1hus sbnul"te and o r 1he stalk. In this case there is a definite cystic
glandulat formations.
structure and the adjacent cells are well preserved.
The hlstogen.;;_. is apparenUy initiated by a pro- There is no evidem;e of degeneration.
liferation of connective Ussue with growth into a
H.&mv Au.n.-, M.D., St. Louis: I wonde.- if this
dilated duct or cyst. During this process the epimight be the same as a fib1·opapiUoma o£ Lhc ovary
thelium Is a lso carried Into the l umen o£ tho cl\lct
or cyst. H tJle st..'\lk is b1·oad (as is seen in thit.s par- in which the fibrous tissue pushes out, enclos ing litticular Instance) the papilloma may be cnlled a tle cysts w·ound the cortex of the ovary. At•o U1ere
"fibropapiJioman; if tl1e sta_lk is narrow and a num- fib ropapillomas of the ovary?
Da. SAPI!lR: Yes. As n matter of !act, the term
ber of pscudoglandular •tructures are formed, it
may be clo,.~ilied as a "pseudoglandular" papUloma. used is "fibrocystoma" of the ovary, although lt may
Thcso tumors arc benign. They may be m ultiple. -also be celled a "fibropapilloma.';
A hemonhngic discharge from Lhe nippl~ is unusual.
'J., Snphlr, 0 .. and P:.rktr. M. L. : Jntraey$11¢ PBPtlloma ot
B ecause there is an h\cl'en11e In, or a new forrno- tho Brtott, Am. J. I~ath. 1.0: 1Kfl·ZHl, 1940.
!.
p!ollfLtt t 'l
tb.U.hlCM PI
Pseudogllllld ulur T ype of lntracysti c
Papillom n
Hi•tory.-(Proscnted by Otto Saphi1·, M .D .. Michael Reese Hospital, Chicago). This 71 year old white
woman entered the hospital because of a lump in
the right brcnst which had been present for two
months. For the last two years she had been troated
by her physiclnn £ot· hypertensive and artcl'!osclcr·
oticheo,rtdiscaso and mild dlnbetes. S ix weeks prior
lo this admission she developed acute pul monary
edema and was hospitaliwd. A diagnosis of an atypical anterior waU infarct wns made. Nothing had
been noted in t.he brei\SL at that time. Phy•ical exluilinntion !'evcnlcd a ,-...ell developed, well nourished
woman in no apparent dlst•·css. T he bren~ts were
pendulous. A hard, nonte ndo1· J'nass, fixed poster-
iorly. was fell In the upper outer quadrant of the
right breast. The diagnosl$ was a tumor of the
breast, pro~1.bly carcinomtt. Al operation, the mnss
measured 2.5 em. in diamctca·. Be-~ause o r the palicnfs condiUon, a sim(>le nlthor than a l't~dkal
masteCtomy was performed. The patient wns dis-
charged, having sustained U1c surgicol procedure
l!llloothly.
The specimen consisted of skin and underlying
hreast tissue measuring 5 by 8.5 by 2 em. Within
the breas~ tissue was a cystic uren memnwing 2.5
ing and branching pattern and covered by a double
layct· of columnar epithelium. As a result of this
complicated set·ics u( inioldings, the epithelium
tends t.o form glandllke structu•·es. Many appear to
be completely isolated from the lumen while in
others continuity 1$ still traceable. The b<tsemcnt
membrane is intact nnd the cells nre uniform in size
and shape.
I find it interesting that so many who have seen
lhls slide recommend t-adical mastectomy. The
weighty decision thltt a breast tumor is a cm·cino·
rna carries with it., o { course, the Implication U\at a
radical m~tectomy ls indicated. As a pathologbl,
one 15 contronted with th.is problem daily. IL hos
been my policy to suy, when in doubt, that 1 just
do not know whether the lesion Is rnQlignant or not.
The b1•east can alwnys be removed at a subsequent
date a fter the paraffin sections have been studied·
but once removed, It cannot be replaced.
'
I do not think that this is a carcinoma but is an
int•·aeystie benign tumor of the breast. The out·
~t.nncUng characteristics arc the long ond
thin finger·
like papillae. Th<> elos<> proximity of the epthelial
cells covering the various papillary excrescences Is
easily noted. The subsequent partial fusing \\~lh the
fo rmtAiion of pseudoglands is identical with that
seen in the previous cas~. 1L shou lei also be noted
!hut the cells of tho•• psoudotubular or pseudo·
glandular syucturcs ' (and I think tl>is is esscntiol
in the differential diagnosis) arc identical with
those lining the ducts or cyst.• in which the tumor
is found. They afton are arrang~d tn two layt'!rs.
Thct·c is no morpholog ic eviclonco of malignnncy.
Thct·c L• no invasion. This papilloma is classiAed
as int-rucystie pseudoglandulat· type of papilloma.
ClinJcally, this 71 year old white woman had noted
the lump in the breast. Although there was no dis·
char·ge from the nipple, pigment laden macrophog<l1S
can be noted in a number of the sections. •
Hc•·cl again, one SC4!s a cyst cont.uining pupilhn·y
Struct ll1"CS, consL~tUng pl'incipally o{ connective tis·
sue and lined by cpitltelial cells. As a matter of
fact, l n this area one can see how the cells which
line the cysts also extend over the papilla. As in the
previous case the pl'imat·y lesion is pt·obably tho
Ftg. 3. tnt-raeYJUt papilloma.
p~~eudogJandul:n-
r~su lt of a stimulation of tl10 connective tissue
\'arle \y.
cm. in diameter and filled with papillary exCTes·
ccnces. The1·c wru; no evidence of invasion of the
~:;urrounding bi'Cust. T he *remllindcr of the breast
measw:ed 16 by ll by 4 ern. Tho nipple showed no
change. On section, the ducts wc•·o diJl'usoly dilated.
DISCUSSION
Orro SAPHl•, M.D., Chicn&o: In this section of
the breast (fig. 3) there arc two l01rge cysts surrounded by dense connective tissue wl>ich extends
directly Into one of the cysts, subdividing it Into two
compartments. Lymphocytes and pigment laden
hbtiocytes infiltrate the connective ti..'Slle. Project·
lng into the lumen of the cysts nre numerolU, thin,
delle<lte st~lk$ arranged in an intricate anasto mos-
which cardes the lining epitheHum into the cyst
Areas Uke these fuse. J1lSulting in pscudoglandullll'
structures. This L• an intrdCystic papilloma of the
pseudoglandular voriety, a benign tumor.
Although not rept·esented In thls collection, the
( tnH>) glandular papilloma J·escmblcs the pseudo·
glandular \)>J>C. I t Is probably tho result of a hyperpluia of acini or duct structures, with secon·
dary ex tension into the dilated ducts or cysts. II
<lifTers from the fibropapilloma' ln that the core
is composed primarily of glands l'athcr than fi brous
tissue. It is easy to difrt>J·entlato between the pseudo·
glandular papilloma and the true glandular papll·
lorna. In the _!2rmer, lhe lining cells are identical
with those of the ducts of the breast; in tho latter
'
the coli• are similar to those of Ute acini. Tn this
.
CLINICAL PATHOLOGIC CONI'ERiiNCE
case. what. were the rea.son:; for calling this Jesion
ll
cardnomn of the breast?
LOUIS A. SciJNETOUR, M.D., n. Wayne: Dl'. Saphir,
I would like to h ave: yow· vJcws on the pathogenesis
of the cysUe dilatation which occurs in these case.•.
So often In cystic disease of the breast (here is
epithelial hyperplasia as \'veil Bl:t connecUvc tissue
proliferation. Wbere do you drdw the dividing line
betwren cystic d isease and these lntracysllc papilloanns?
Dn. SAPnnt: The dividing line is the diffuseness
of the process seen in chronic cystic mastitis. 'nte
di ffc.r cn ce lies in Lhnt the intracystie pap illomas arc
single lesions confined to one area; in chronic cysUc
mustitis. a diffuse process, there arc intraductile cellu.hu· proHfel'a tions of various sorts, including _papil·
lomas. There tn ay be, perhaps. a cornmon underJyin¥ factor as yet unknown.
HENRY ALLEN, ·M.D., S t . Louis: How do you interpret the epithc!iul-like cells oul in tl1e fat?
On. SArHm: 1 do not think 1l1 at tJ1is is evidence
or carcinoma. I think the cells nre normal duc1
structut·c~ of th e b nw:;t, ot· fat ty bruust. Remcmbct·,
the woman is 71 ycun; old!
LAua£N V. ACKI!Il>IAN, M.D., St. Louis: I thinl<
thot t his l ~s io n, whllc it is quite common, is m or e
frequently misdingnosed than nlrnost any othC'I'
lesion of the breast. L1 my experience, nothing has
huppened to those patienl.s who hnve bad only sim p le wedge l'esections. It requires much mo1·e cout··
age !or a pathologist to eaU a prol!feraUng lesion
benign th•n to sny, "I think it might be cancer."
In the latl.et• lnstnnce a radical mastectomy is p e.1··
[o11ncd. the patient may be c ured, and the patho1ogist is absolved of •·espons!bllity. However, I tbink
il behoove$ the pot.hologisL lo t.uk~ this t•csponsi·
b ility on the basis o f Ws knowled go o f the outcome
of the prolifel"ating intraductile papillomas. I think
this on e is pe rfectly benign.
Dn. SAPHltt: I might m ention thut
Wl)
Thel'c was slight iixotion of Lhe ovet·ly ing sld n ~;~.nd
the nipple was retrllcti!d. No axillary lymph nodes
were rcll A a-adical mastectomy wns done.
Tho brenst measu•·ud 15 by 11 by 6 em. A thicl<
yellow material could be expressed !rom the nipple.
ln the brca!l:t were \-wo large, thick walled cysts,
each measUl·lng 5 <:m. in diameter ~\nd containing
bloody fluid. Projecting !rom the wall of one of
these wet-e soft pink excrescences which appeared
lO extend into th~ !:iUI'l'OUndlng tissue. Several
lymph nodes were found in the axillary tissue.
DISCUSSlON
Orro SAPIIIR. M.D., Chicago: This section (fig. 4)
shows the w..U of a cyst &om which project numerou• thick papillary excrescences. The stalks are
b•·oad, e-dematous and sometimes poorly, and other
times richly, vascularized. The covering epithelium
consiMts of supedleitLl rather low col umnar cells ar·
ranged perpcmdicuhu· to the basement membrane.
These cells have vesicular, often oblong, nuclei.
The deeper layer iS composed Of IDOTe Spindle
shaped cells. T hey va1·y considerably in (hickness
and ofl~ project int.o the subjacent Ussucs form·
ing irregularly circumscribed collecUons o( cells.
Thnt (hese co!!s h ave likewise p roliferated u pward
with elevation and in(oltling of the- col umna r cells
is evidenced by the formation of alveoli which are
lined by_co lumnar epitheliu m. In some at·ens tbere
arc ocini lirwd by cuboidal ccBs. No evidence of
invasion or celluJar malignuncy is s~cn..
hll.ve fu)..
lowed th~ cases which I have shown you thus far.
To date nothing has happened. Muslectom!es were
n ot. perfot·med.
1. S3pb.lr. 0 .• and PArker. t..t. 1..-:
lnlr~c
the Breast. Am. J. Path. "16!1"'-2.10, HHO.
It,
?!
PaJ•IIIoma o!
(¥1Li..MV lACCJoiOU~
·r ,·a n sitional Cell P u[lillom n
Hist0111.- ( Presented by Otto Saphlr, M.D.. Mich"c! Reese Ho•pi(ai, Chicago.) This 61 year old
white woman cn,tel'ed U1c hospital bccauso of cysts
.tnd swelling of the .right breast of six to seven
mon(hs' cllll·ntion. S he hod noticed a soH "blebllk e'' a1·ea on "her righ t b rcuHt .about six months ag o,
which was tender on pre-ssure but otherwise ,\-.as
not painful. Thei·e was no discharge from the nipple.
Gmdual!y the mnss ln<:reused in size but the patient disregarded It until about one to t wo monU1s
before adrnission when she notiecd thal the ent.iro
bt·cast was enlargc·d. The fm:nily history was non·
contJ·jbutory. On physical exan\ination the r ighl
breast was considerably lnrger than the left. It
was replaced largely by n semifluetuant, nontender
n\UJtinoduhw mass measuring 10 e m. in diametCJ'.
Fia. d. l n lrtlt,YsUc p.'lplllomu.
prlncip~lly
trt1tU1Ulonnl type .
This is a more difficult tumor than the foregoing
one. It r esembles th o last lWO cases in that it is a
benign intraeystic pnpilloma of tl>e breast, but dirfet'S in one imporlunt aspect• .Microscopically, in
most or the fields, (here is • proll£cration of epitheliul cells which du not vary in s ize, shnpe or
staining quality. Often only nuclei nn> present and
the cytoplasm cannot be cleal'ly seen or, at least,
l;l\ Cl'C n:re n o d istinct c<!llulm· membl'ones. The nu ~
clei are vesicular. sometimes ~lightly elongated, and
resemble morpholoaically (and tim is the impar·
t.an t fca tl.ft'C) IJ10so seen in certain pnpillary tran·
CLIN IC AL PATHOLOGIC CO NFERENCE
siUonal papillomas of the urinary bladder. Here ably, he will ask questions more or less of this
and there masses of these cells arc grouped to- nature; ··well- ! was told that in a carcinoma there
gether; the most superficial layer or epithelium~ is invasion. mitoses, anaplasia and tumor giant
which is low .cuboidal, is similar to that lining the cells. W ould you show me Ll,ese?" It hns been my
larger ducts or Ute breast. Throughout the sec;tions, e..xperic nce Lhat if 1 could not convince n medical
and often in Lhe midst of these lumox cells, the re stude11t tho.L t.hc lesion, on morphologic grounds,
are a numbe r of glandular struc tut'f!$. The cssen
was a carc inoma, it pt·obably was not t1 COI'cinoma.
Uul rcatu•·os. ther efore, arc trans iUonnl cell-like
M. P I NSON N&AL, M.D .. Col um bia;
Sl\phir,
epithelial cells and pscudoglandulm· s l.r ucttu·es.
Fww Is one 1.o d irTcrontiatc this lesion (t·om D tr ue
Tlte pathogenesis, in my opinion, is os follow: Tile endothelioma w ith pseudogland !o•·mnllon'l Iiow
papillomu arises fl'om a proH£e rulion o f U1e cells cnn on e can ito benign tumor when L.hcrc arc l ymph
which arc cl osely r elated to the deeper Ioyer of the \•esse! pcrmcntions in the capsule? The slide I bad
duct epithelium. The prollieration ol the tumor revealed thrco lymph vessels completely packed
eells Is apparently not uniform and hero nod there and filled with tumor cclls.
stalks are formed. As a result the more superficial
DR. SAPllm: In nnsw.,.. to the first question. "Why
lining celL, arc carried in to the lumen o! the cysts is this not nn endothelioma?" I do not know. I have
and give l'isc to the pseudog lnndulnr slruc~w-es.
neve r seen an endothelioma of the brcnst.. rn my
Durina the proliFerative phasa numc1·ous small opinion Lhesc cells l'esem ble epithe lial cells. [n anblood vessels nc.:company the pnplllury growth. swer to the second question about involve:mcnt of
When ~h csc vessels Tupture. hcrno1Thngo occurs the ly m phatics, I do not see how one con I'Ulc out
into the cyst or duc t and the cHnicnl s ign ot· SyJrtp~ a smal l duct struc ture. In a hematoxylir\ unc;l oosin
tom of bleeding from the nipple occurs.
p repat·ation it Is d ifncul t !o differen tiate u smull duct
The tcrrn ulransit.ional cell paplllornn'' is used from a lymph vessel.
to denote not only this type o f cells o! the tumor · DR. NEAL: The lymph vessels are actually in the
but also to point to the similnrity in prognosis be- capsule; they nrc not within t he tumor.
tween it w>d that found in the ul'innry bladd.,r.'
DR. SAPnm; If you bav" seen lymph vess<>l inWe have watched a number of such papilloma..,. volvement. lhen it is a carcinoma rather than a
dosely and have found that they arc more
transitional cell pnpiUoma. I did not see definite
quently multiple than any other type. Recw·rences lymph v~els conta ining tumor cells. Or. Ackerarl' common ond often show morphologic evidence man, w hat do you think of this tumol'?
orcsu-clnomo. In o ther words, here is fl hLmor o r the
LAo nt!'V V, A cKtRMAN. M.D., Columbia: [n fur·
brc11sL-u papilloma- which I would like to call a ther r eviewing !hi$ t umor (J an uary 1049) ! would
rnpiUomn oE U1e l:rtmsitiona] cel l vn1·ic ty. It is never agre e with o_
,., Suphlr that this _is not n cnrcinoroa.
in\'aslvc but g rows within the due l of t.he: cyst. Be· I was n1uch inlorested in thi-s particular neoplasm
cause of the large number of cells and the paucity because. us I recall, in yow· article on your g1·oup
or stroma, it is soft in consistency u.nd canool he. o f pap illomas. this w as the rarest form. I would
pslpstcd. The only complain t clidted. at times, be jntel'ested In how many instances or this ty!><'
from the patienL is a hemorrhagic discharge from there was actual invasion and, in this eroup. how
the nipple.
many developed actual metastases? Hove there
l n U1c photomicrograph of lhe section, there is been aJl}'t case$ in which simple ex cision wns done
the wall or a cyst from which project n umerous, with a follow-up of the patient? I n those cases
thick papillary excrescences. The stalks are broad, which you fo llowed, has an ything happened?
edemntous and some times poorly and sometimes
OR. SAPITm: Yes. Unfortunately, it hos. 'L'he pa·
richly wu;culnd z.ed. The covering epithelium con ~ tie nt •·etu1110d w ith metastases in the lymph nutles
sisl<' of a superficial layer of columnar cells a1·- and " recmTance, Ol' tumol', in other portions of
rnngcd p~11lcndiculat·Jy to the bnsement me mbrane the breast. r have ne ver seen it in any o£ the other
and n deeper layer composed o! cu boidol cells. The papill omos. I should like to st.ress • gain iL~ relalatter vnry considerab]y in thic-kness and often tion.c;.hip to tl'lc primary -papilloma o£ t.hc urinary
project into the subjacent tissues, forming irrcg- bladder, which. morphologically at lea.•L. is a bcularly cin:umscribod collections of celt.. That thes" nign t umor. but which will almost invariably re·
cells have likewise prdliferated upwnrd with ele- cur. T he Regis try classifies such tumors • • careivation nnd infolding of the columnor <"<>lis is evi- noma, G rade I. II I may,J would like to CAll this
dcnccd by the formation of alveoli which are lined tumor n cnrclnomo. Grade I, rather than a papilloma,
by c-olumna1· e pithelium. In some Ol'Cl.IS lhe re are although on morphologic grounds it is n pnpi llama.
acini lined by cu boidaJ cells. Tl•c•·c is no evidence
D k . A CKERMAN: How man y cases have you seen
of invasion O J' cellular maligmmc~· and, therefore, in which motost.use.s dev~oped?
It ennnot bo called a carcinoma.
DR. S,\.])Tfl1t: l cannot give y ou an exflc t figul'c.
I should like to d igress at this point, II I may, to
F . P . E. BOANS'J'W<, MD .• H errin, Ill.; D r. S ophll-,
cite n personal experie.nc~. Whencvel" I find i1. diffi. ·w ould you consider a simple mastectomy sufficient
cult to decide whether a lesion is benign or malig- treabllcnt for this tumor ?
nant, I invite a medical student to study the slide
DR. SAPnm: U a surgeon can convince himself
with me. I tell him that it is a carcinoma. lnvnri- that pressure upon_only one quadrant ol the breast
4
n.·.
rre-
•
cnus~s ~ hcmolThaglc discl>argc fro m the nipple,
and to certain implantations on the pcritonoal sur·
I would, 0\ink it adequate to do a wedge resection .
In this c.use I would recommend a simple mns..
race.
Most instances of bleeding from tl>e nipple slg·
nify an intraduetile proUCeratlon or epithelial celh
with rich vascularization. Such proUCcrntions of
epithelial cells may ix> found in so-called chronic
tectomy.
Do. ACJ<ERMAH: The question often arises whether
an individual breast lesion is benign or mnlignanl.,
or whether it is almost malignant. I try to answer
the question, if I ca~ with either a •'yes" or a
·•no." Expcrlcn<:e has shown that a simple mastee·
tomy Calls t.o remove all of the breast parenchyma.
cystic mastitis or &himmclbusch1s disease, in intra~
ductile papillomes and in intraducUic carcinoma
In Schimmelbusch's di..,ase, or whatever one may
call it, a lesion can easily be palpated In the breast
and often multiple dense areus arc noted. A card·
noma is also easily palpated and o£ten presents char·
nctcristic features. However, the int1·ncystic papil·
lomu of the transitional cell variety o ften cannot
be palpated. I£ one can rule out a blood dyscrasia,
vicai"lous men:!.1.ruation, rare vosculut· tumot·s and
hmmutom_as, then the bleeding nipple, in the nb~
Flg,
a.
lntrll¢y~Ue
pnpllloma. prin¢lp:..Uy transltlonnl type.
In nddlllon, if u simple mastectomy is done fo•· n
suspicious lesion which, subsequently~ pl'oves t.Q
be true hwnsivc carcinoma, one is tbcn in a tl)l"ribl e
fix! F ii'Sl of all, in the subsequent n >dlcnl mostcctomy the pl'cvious operative field must be
&voided by a wJde excision, otherwise the chances
of Joca1 rccuuence are increased. I would sny tllA.l
it is either everything, or i t is nothing. Either the
pathologist calls the tumor malignant and a radical
mastectomy is donet or he calls it benign. In my
opinion. 8 simple mastectomy is a sort or ha!Cway
compromise with the situation. In the g,r oup or
CA~ whjch we followed, local recurrence was
common despite the fact that the carcinoma was
smnll und a simple mastectomy had ix>en done. The
prognosis in this group was -poor.
Dn. 5AJ1HIR: or course, that is the ideal an~wet·,
if one ctm give such an an!.·wcr. However, there ot·e
tumors which, morphologically, arc benign but
biologicnUy m:e not; and a patient with ~1 hcmor·
1·hnglc dlschaJ·go !rem the nipple may have no pftl·
pable tumor . What would your answer be to the
su1·gcon':; que•·y. "What shall I do?" In this instance,
t.he•·e was o soft, bleblike are.a noted by the patien t
slx months prior to operation. but no iumor.
The multiplicity of these transitional cell papil·
lomas o£ the breast may be explained either on the
basis or multicentricity of origin or by implantation
of tumor cells in ncighboring ducts. Such implant&,
pe'r se, arc not necessarily evidence of malignancy,
but they mny be compared to tissue culture growths
sence o£ a palpable lesion of the b1•east, Js the result
of a transitional cell type of papilloma. Becnuse of
tho foregoing and because tl1c tumor cannot be
palpated, it seems reasonabl~ U. me \hat a simple
mastectomy, with all its faults, should be done.
Perhaps, fu the future, the demonstration o£ tumor eclls within the discharge of the nipple might
enable a correct diagnosis t.o ix> made before opera·
tion. I am going to show some examples. It might
also ix> possible in the future that. if a Huggin's
test is done, a more definite dingnosi• might be
mnde4..
This is a Papanicolaou stain (fig. 5) of n discharge
of the nipple. The patient p•·ovcd lo hnve u tr·ansi·
tlonul cell papi1loma of the breost tmd not n cart:Jno·
ma. This is a photomicrograph mud& from n smear
taken from the secn~tion from the nipple 9nd stained
according to Papanicolaou. The patient hod n tran·
sltJonnl cell carcinoma of the b1·east. Tn this caSa
we. actually made the diagnosis of carcinoma rather
thnn papilloma on the basis of cells. There is a
large clump of cells which I called malignant tumor
cells. A radical ma.ltitectomy was done and the lesion
proved to 1x> a carcinoma. The thennocoagulabillty
test of the serum which wa.< perfected by Huggin
has been used in our laboratory In conjunction
with breast biopsies. Of twenty-four carcinomas of
the breast, t\venty·one gave positive ond thrc.c neg·
ntlvc tests. The false negative cannot be expln.incd.
r would like to know if anybody has ever studied
Huggin's test in association with papUiomlts of th~
ut·tm•J·y b1addcr?
MARTIN SILBERBERO, M .D., St. Louis: Dr. Snphir,
1 wonder whether you or anyone clso hu~ hod ~x~
p~l'icnce with: the results of the phosphatase rcnelion in regard to breast canCCI", Seligman nod
coworke.r s fOUl)d differences in the outcome ol the
reaction in benign and maJignant. mammary lu·
mors respectively.
DR. SAPum: I do not know anythh1g obout it.
DR. SILBEI!Bmc: The aforemenUoned investigations have oocn published in the Jou.....,l of the N4;
tiona! /Tt$tituu of Cancer, 1948-1949.
HENRY PnncmroN, MD., SL Louis: Do I under·
stand thalone differentiates by cytolocic studies ix>-
tween the transitional cell carcinoma and transi·
UoMl cell papilloma in the breast?
Da. SAPmn : Yes, 1 would like to; I cannot do II
)'el
DR. PIIIKERTOs: ln the cases which metastasized.
there invn•ion at the base of the pedicle of the
W1IS
tumor, or did lhc:y metastasize without showing
any Invasion ol the breaot itself?
DR. SAPimt: They did show tnvasion of the breast.
DR. PIIIKtRTON: In the a•se of bladder tumors, I
have not been convinced that the degree of cyLologic mnlignnncy ls any good indication of the
prognosis. I hnvc seen some that were quite ana·
plnsUc nnd yet went for fifteen or twenty yem-s.
So, 1 wondc.t· ir puroJy cytological observations are
going to tell ono whothct· it is benign or malignnnt1
DR. SAPHD1: I u.a:n::e wlth you. As a matter· of fact,
I have studied a series of papillomas of the urinary
bladder •nd l believe thot the anaplasia often is
no indication of the degree of malignancy.' In·
vasion of the prostate determines the development
o{ metastase..o;. Variation in the size of nuclei and
anaehromasia in urinary tract twnors are not suffi-
cient criteria for a basis of the degree of malignancy.
DR. AcKERMAroo: Why not ask some of the sur-
geons whether they can feel intraductile papillo·
mas? !always thought one could 6nd them at some
Ume or another.
JOHN J. MODLIN, M.D., Columbia: In my rathe•·
Umited experience with bleeding from the nipple
al this institution. I have gained the distinct im·
procUc:e has been not to dissect out a solitt11'Y duct,
but. to do-what I consider an innocuous p1'ocedurc
even from t.hc cosmetic standpoint-a wedge rcsce·
Lion of the breast. If the pathologist then says that
the p~ is not limited to a single duct but i•
p~<>nt
tn a number o£ ducts, a simple mastectomy
is done. On one oc:casion, during my absence from
the ElliS Fischel State Cancer Hospital, a resident
did 8 Mldical mastectomy for a bleeding nipple in
which there \vas no palpable mass. w~ were graU·
fied when Or. Ac.kc.rman found cnrcinomn in at
lcnst one site and, I U1ink, in several sites in that
ptu·tlcultll' breast. If a carcinoma is found in tho
sul'glenl specimen. from a simple mastectomy, ond
it is not. impossible to find, then
ond docll o rndi,:a1 mastectomy.
one
goes ahoud
Dn. P~to<&nToN: I would like to ask, D•·. Saphlr,
whethe•· you think the radiologist has much to olfc•·
by injection of xadivopaque. substances and tnklng
x-roys for the purpose of outlining the ducts?
DR. SA.PinR: I have had some experience but (rom
what 1 ha,•e seen, I would not think it a good pro·
cedure.
1. Sophlr, 0 .. R.nd Par-ker. J.L L.: Jntr.te")'1"1ic. P.1oU.lornl ot
the BrMJt. Am. J. Path. 1$:69•210, 1940.
Z. S:.Dhlr. o .: Cc-ruin
~b
ot Primary Carelnoma of
lhe Urfnnry Blodder. Urol. ._ C\lta:n. Rev. ·18:55!-554, l&-&4.
l~a~~V YMIU.C&.LA
S. Intrucy$tic Pupillary Carcinoma
wedge resection of n quadrant of tbe breast. To
date, none of these patient.. ha.• returned with £rank
cancer of the breWit or evidence of distant metastases. As Dr. Ackerman emphMized, those cases
Hi~IOMJ.-(P•·esented by Otto Saphir. M.D .. Ml·
chael Reese Hospital, Chicago) . This potient. a
53 year old white woman, had had a lump in the
dght breast for four teen years. H had couscd he•·
no discomfort except for pam in cold wcnthcr.
About two yea1-s prior t.o entry to the hospltnl it
hod begun to grow in aize and 'she noticed for the
first time o reddish-yellow discharge from the nip·
pie. She was a known diabetic under treatment for
many years. Fourteen years previously she hod
hod a hystnrectomy for tumors, an appendectomy
and the removal of a cyst of tbe breasL On exam I·
nation the breast.. were large and pendulous. There
in which simple mastectomy was perJormOO and in
WAS a round. indurated# tender, fLxed area meas·
which carcinoma was found in the operativ~ speei·
urln.g 5 by 7 em. at the medial margin of the
nipple. the overlying skin was freely movable. ln
pression thnt if one Js persist~nt in the extunination
of t.he brcnst, one con localize the site of bleedilJg
in nearly all cas~s. In many inst.ances1 a small tumor
can b~ pnlput.cd ot the site where pl'e:ssurc causes
the nipple to b1ccd. For this reason. we have usu·
ally perlormcd only local excision or, at most,
me~ subsequent radical mastectomy was techni·
eally much more difficult. An attempt should b~
made to circumscribe the entire previous operative
the lower outer quadrant there wns another mnss
mea:~Juring 6 by 7 em.; lt wos freely movable, soft
field. In one potlcnt at the Ellis Fischel Cancer Hos·
•nd nontender. No axillary lymph nodes were felt.
pital simple mostcetomy was followed by a t·adical
At operation two separate masses were found. A
radieal mastectomy was performed.
The biopsy specimen consisted or an incguhu·
maste-ctomy rmd 1t was necessary to excise a large
amount of skin from the chest wall with immediate
grafting of t\ll unnoc~$snrily large area.
WtLLTAM w. nuuav, J\+1.0 .• Memphis, Tenn.: Somo
o~ our surgnons have been able t.o insert a probe
into the duct from which the blood came. Using
the probe os o guide in their dissections, they have,
in several cases, successfully located intraductilc
papillomus.
E. D. SUOAftBAKER. M.D., Jefferson City: I think
that although a tumor cannot be felt. the duct containing the papilloma can he localized on careful
palpation. And U the surgeon is not too persistent,
he can find it naaio at the time of operation. Our
mas• of yellow tissue measuring 8 by 8 by G em.,
in the ccnte1· 'o f which there was a poOl'ly circum·
scribed. firm, granular, gray and hemorrhagic mass
mcsumrl_n g 3.5 em. in diametet·. At one margin the1'e
were several small cysts filled with clear brown
fluid, tl>e largest measuring 1 em. In diAmeter. Pre·
scnled separately was a breast. measuring 22 by
13 by 7 em. Extendtng from the nipple was • recent.
\()OS(!Iy outurcd tncision meaouring 8 em. in lensth. ,
markina the site of the biopsy specimen. A dilatod
duct was encountered 1 em. below the nipple; thi5
wos filled with a papillomatous mas..'l measurinc
CLINICAL PATHOLOGIC CO)'IFERENCE
7 rnm. in diumcter and 1 em. in l ength. Consecutl\fC
sections of the breast revealed num~rous cysts
filled wUh b1'0wn fluid, and small islands of pinki•h
gray tis>Juc isolated by large amounts of fat tissue.
The nlt3ch <'<l stl"iatcd muscle showed no mosses.
In the axillary lis>Jues there were two lymph nodes
mc:.suring 7 mm. in diameter; these were soft ond
pink.
DISCUSSlO)i
Orro SI\PHll!. M.D., Chicago: Immediately subjacent to t he main d uc t of the breast is a large cyst
so~called ·~Iue"
eellsJ ularge" ce.11s. or sometimes
"Wu.sserhelle11 cells according t.o KJ·ompcchcr.
Their cytoplasm is well outlined and their nuclei
ore hyperchromatic. Krotnpechcr, 1 who first de·
scribed th"m, considered them to be misplaced
sweat glands. Because of my interest in the3e strue·
tures, 1 have examined numerous sec:Uons of breasts
removed from infant females but hnvo never been
able to eon\rincc m,y sell
their presence. They art
commonly seen in chronic cystic mastitis and in
othea· dh1eases of t he breast, parlicuhuly in connection with papillomas,
LAun£N V. AcKJJnMAN, M.D., SL. Louis: t hlld
more Lrouble with this one than with any other, but
( e nded up by writing it down os benign. B ut those
two nodes we\'e ncglltive, is not thnt COl'a'uct?
or
Dn.
..... .. '.:~Jt
;...
:..:
f'-'- '
'-~ ~
~"':
j .. ~.....
-, ••- ~ .
~..,.
ll"lg, 1$. lntroey:r;-Uc: papUloma.
~~!
..
- 1
~ -·
.
SAI)HI.R:
Yes.
On. ACKtHMAN: I tl1ink this Is certainly the most
debatable one; I would nol orguo too strongly
about iL
Dn. SAPmn: And what would you hdve reo·
ommended that the surgeon do?
Da. AcxmMA.~: In this one I agree with you.
This is the one in which there was t.rcmc.ndous
d oubl; i do not feel ftatfooted about this dingn0$is.
DR. SAl'WR: Any other questions or argument!
Then I assume that all agree thai this Is a papillary
carelnoma.
1. Kromoe.;he-r. £.: Zur Ri5tottenese und Morohologle der
C)'!CtA!Jilh:umna (MaLi•dle kystlque R eelua. cratadenomta Schlntmtlbullc:h. M;1~1iUs chronica q~tleA Ktln i~J des lntr·.a.k anaiJk·
uJEII·en K.ygtadcnoms und der Kystadc:noknr'.tlnom!1 (lor Brutt•
<lrli~ . Bc:ltr. x.. path, Ana, , \ J . z. 4.ll g. Path, 62 :403~472, J916.
(fig. 6) IIIJod with an intricately bra nching sessile
popllloml\. Tho s tal ks are broad and composed o1
~ MW~ "'"'~"""' PllVIMJII)tS
thick, hyullu izcd connective tissue wh ich seems to
"· Neurofih rO'Sftl'COIUU or the ' B··euMt'
comp1·ess th~ enclost>tl small glands. The cells cov ·
H isto?·y.-(Pxesen t<!d b)' S. M. Robson, M.D.,
erlng th ese stalks are morphologically similar to tl10
St.
J oseph Hospital, Ft. Wa~o1e, India na). In 1942
cuboldol cells of tl1e ducts. Tbey are arranged in
diso,'dcrly masses and glands of variable si<cs. 1.h1s 42 year old white woman u ndcrwcn.t romoval
Ther~ Is > pronounced lack o[ ccllular uniformity. of a lump of the breast which was diugnos.ed as
The nuclei va.ty in size and shape; some a1•e h)'PCr. . ..cystic disease oi the breast; fibr<Hldcnoms." In
chromatic and pyknotic. Mitotic figures are occa- February 19<18. following the surgeon's report that
sionally sc<n. There is extension beyond the base- a I"QCUrrcncc was present, the slides from that spement mcrnbranc into the periductile connective lis- cimen were reviewed. Giant cells nnd mitotic figsue, as well as into the stalks. In addition, there ures were seen, and it was suggested thot a stromal
arc groups ol glands which hear no resemblance neoplasm wns probably present. The following
lo those described above. The lining cells are lnr-gc month, March 1948, the recurrent mnss wos exand <:olumnw· with t~bundant pale, granular cyto - cised and a diagnosis made of ufibro·adcnoma. inpla~ms. The nuclei are p lfM)morphlc and some o!tcn
named." In November 1948 a second l'c<!Url'ence
rench giant p l'oport.ions.
was exdscd ; the -se<;tions arc pl'epnred h·Qm this
I think thi::; h; a n example of an intracystic pnpil- tlssue.
OTTO SAPlilR, M.D., Chicag<>: This •ee<iOI\ (fig. 7)
lary curcinomll. ').'h e tumor cells resemble those
seen In Lhc tr ansiUona1 cell pap ill(tma w ith t ho ex- shows an -invasive tun1or compo..c:ed of whol'IS and
ceptiOn that there is a naplasia, there a I'C ulyplcol in terlacing fasciculi of delie~, to wAvy 1\brlls and nu·
mitoses a nd there is evidenc" of invasion. Jn 11ddJ· merous cells. One ma1·gin is smTounded by lhick
tion, the tumor is multicenb·ic.. There are many bands of fibrous tissue which <>."<lend into the tumor
dllntcd ducts filled with hemon·hag ic b1·own mo· fo1• a shortdist.ance. The cells arc ovn l or polyhedral
t.crinl tmd cysts filled with tumor mas..cocs and with o small amount of acidophilic e~•toplasm and
bloody material Grossly1 the main twnor is h cmor· markedly pleomorphic nuclei. The lntt.c1· nre often
slender. hyperchromatic and elongnted, or lar-ge
rhuric.
An intci"C'S-ting side issue is the peculiar glan· and 0\'al. The chromatin is coarsely granular and
dulur structures lined by pale-staining (in the hem· there are one or two lar-ge nucleoli. Rare giant~
atoxylin-cosin stain) epithetial cells which are lor · can be seen. Mitotic figures are (requcnt. A van
ger thllll thos" ol th" ducts or acini. These ore tho Gieson st-ain reveals a paucity or fibrous tissue.
-
CLINICAL PATliOLOGIC CONFERENCE
There are minute foci o£ necrosis and scattered in·
ftlb-ations of cosinophils, plnsma cells nnd many
lymphocytes.
Almost everybody calls this lesion eithc•· n 6broATCOma or some sort of o sa.r coma. I consider it
not only a sarcoma bu~ more specifically, n neuroflbrosarcomn. This is obviousl)• a breast tumor con·
slsling pl'incipaiJy o f mesenchymal str uctui'OS, al though epitJ1elinl s tl'uctures ut:e presen t oceitsion·
nUy. Th e diffc•·ential diagnosis includes: (1) adenofibroma of the breast with proliferation of connective tissue structures; (2) adcnosarcoDUI; (3) recurrent fibrosnl'coma, and ( 4) ncurofibrosnrcoma.
The outstanding characteristics are: a n iutorlocing
of 6bers, pullsuding of nuclei nnd invasion. CheuUe
a.nd Cutlel·1 believe that tl1o most common type oi
mammary sarcoma is the so-called malignant transformabOn of connective tissu<- which is part of an
od~ofibroma and, hence, tho le.rm, adenosarcoma.
They believe t hut a fibrosal'cOmu o£ the brea~t. with..
out epjthellal clemen ts is e:<tl'eme)y t·fln~.
Morphologic evidence thut this is a malignant
tumor includes invasiven~ anaplasia, a fC\\. alypip
cal mitotic figures, a number of multinucleated
tells and a paucity of glandular structures. Although these gltmdul ar stTuCtUl·es may huvo been
1u·esent, they were most likely invaded and cver'lt·
uoUy replaced by 1he tumor. This point I• addi·
Uonal cviden~-.. of malignancy. I admit that there
i$ no absolute proof to substantiate my diagnosis
of n neurofibrosarcoma. However, in lhe van Oicson
slain the stl'omn is either yellow n o1· red. There
Is a tendency toward palisading and plexiform arrangement, which I conside1· characteristic o f neurogenic origin.
LAmu:.• v. ACKER>lAN. M.D.. St. Louls: r believe
It is important In this tumor. rcglll'dless of its label,
to indicate thnt It is of fairly low malignnncy. Although l ocal rccu •Tenccs or e frequen t, distant
metastases a1'C ¥·equent. Wide radical excision
·'Probably will be curative. Now. [ have difficulty
in recognizing tumors o£ neurogenic ol'igin on the
basis of their microscopic pattct·n, or on the basis of
lnva.Uon, because l l;hink thot fibrosarcomas ubo
in"ade and J•ecu•·locally. It Is my !eeling U1alnouro·
genic sarcomas are relatively rare tumors 1md that
malignant changes in a neurofibroma are also rare
occurrences.
DR. SAPHHt: Il is quite evide nt that we <.liflcl' in
opinion. I hove mflde.t.h~ d ingnosls of fibrosurcoma
only on ra1·e occasions. As you stated. Dr. Ackerman. local 1-eeurrenee is frequent in both the neurofibrosarcoma And the fibrosarcomas. In addition,
whenever I call u tumor a ncurofibrasarcomn. I always add a noto stating that. it will recur locfllly,
II not completely removed, but wiD not l"'oduce
metastases. In my experience such tumors become
more cellula•· with repeated rocurrences until. ulti·
mately. they loll into the category of neurogenic
surcomas. [n the latter mett\!Stascs can occu r.
LEo Lown.o:R, M.D., Tulsa: Ten years ago I made
a d lognosis of a low gr~de fibrosarcoma o f the leg.
Recc1"tJY, I saw tJ·Iis patient aguin and -t here wos
no ev-idence of 1'eeunence. NaluJ'aiJ~r, I questionocl
the vulidity of my diagnosis and reviewed the slides.
In 1938, at the oge of 24, this p.•lient hAd been in an
automobile •ccidcnt and had suffe•·ed a severe
bruls<> on the lntcn•l aspect of the left thigh. A
slow! y growing tumo•· developed at the site of
trauma. One year luter tb_e t.u mor was excised and
a microscopic diagnosis ol fibrosing myositis and
fascinl fibroma was made. Six postoperative x·rny
lJ"(!o&lments were given. During the next year the
· h.uno 1· rccuncd. The patient had lost twenty pounds
ot weight. This time~ two y Clll'$ after .ihe initial
troull'I01 a thorough sw-:gica) cxposur·e was performed. The cnti1"e semitendinous and one half o(
the semimembranous muscle were involved by o
ciHTusco mass which was removed. )'licrosc:opiclllly.
in nddition to lhc ribrosis and ch l'onic inflammation
of th-e muscles, th n1·o wa.s an infilt l'ating neoplmun
F'IIJ, 7, Note 1-hc lnte.r-ladng t\bcrt, u'e rr.any spindle~
shaped nucle1. and thCl: tmdeney towArd J)l.pilla.ry tlrra•\gCl:·
ment of P'O\Jps or ftbert..
composed of 6broblastic ceUs which were compnm tivcly few in number. They exhibited no onaplnsin bu t p roduced nn a bundont flbt·illat• slt'Oil\B
which did not have the characteristics of collagen
with special stains. I made a diagnosis of an huutrnti ng, low grade, fascial fibro.Sal·corna or ncurofibros.nrcoma on the basis of a po$t·t rtt1.1trtatic fibrosing rrwositis. I added the sUnl:c note whiCh you clid,
D1·. Sophir. that this tumor would 1-ccur if not en·
tircly removed. but that metastas~s would be unlikely. Ten years have elapsed $ince I made this
ditlS no.sis. .!\fter l'e\·iewing the sUdes with some
trcpidntion I confirmed my previous diagnosis of
ten ycnrs ago. Thor o is no doubt but that there WHS
a low grade fib•·osn1·coma and, despite the mugniLudo, tl1c entire- lesion has been excised.
DR. SAP!UR: It is interesting thnt many of these'
tumoi'S at·e (ound In the ~o£t tissues of the lower
c~tremltles, such as you have cxpct'icnced.
Loul.S A. Seiu<Erotn, MD., FL Wayne: Wc io1lowed the patient, whose case is now under discus-
parallel to \he tibri\s. A\so JlrQsent are slitlike ~pac..
and round cells. Subjac<.>nt to this are thick bands oi
sion, for s~veral yeuxs. There is a mistake in Lhe
hislo•-y, which I boliov<.> is out· faulL. The patient
including lymphocytes, round cells, plasma cells
wns .....,., in 1947 rather than in 1942. At that time
there was a proce$S which wo relt was primary epithelial in nnlure, and a diugnosis of cystic disease
was made. We thought that there wen~: associated
fibrondenomns. Sbc months later the surgeon reported tl1at there wns a recurrence which, incidcntally, was in the upper outer quQdrant of tbe
bt-.,u$1. We experienced considerable difficulty in
convincing him thai It had originated In the b•·oast.
\Ve reviewed U1e slides and cut new sections. The tc
were a few atypical mitoses and the possibility that
this was a nonepitheliul neoplasm, possibly a liposarcoma becoming a HbroUposaJ.·coma, was considered. Six months afte1· the operation f•·om which
this slide wns derived. a simple mastectomy was
performed. The breast was involved ~ifTusely.
About six months ago •he developed ascites and
pleural effusion. Tumor cells we:rc found ln the
pleural lluid. Tbe patient died about two and on<.>
half months ngo. Un[ortunately, we wo•·c unable to
get. permission for necropsy.
1. Cheatle. 0 . L.. Md CuUtt. l1~ : Tumors of lhe- Brt.;.t,t.
Thtlr Patholojty, Symptoms, Dlaf:noois :md Treatment. Ph'la·
delt)hla. J,
a: tJppln<:ol,1 Co.•
1931.
L~l'\t.• ... ) ...'1-"
'7, Cy•tic• ) 1yofibrowa
Hi>fW'I/.- (Presentcd by Leo Lowbeer, M.D.,
Hillcrest Memorial Hospital, Tulsa, Oklahomn ).
Four years ago this 51 year old N~>gro woman de·
veloped abdominal enlargement and a paracentesis
yielded moro than 4 gallons of fluid. During the
following four years she was tapped repeatedly llond
each lim<.> a larg<.> quCU\titY of fluid was obtained.
She wus admitted to the hospital becau$e of recurTence o£ abdominal enlargement. A cl)l,ical cliagnos.i.s of cirrhosis of the liv~r or abdominal maUgnancy was made 'nd n parl)Centesis perf'ormed,
yielding 16,000 cc. o! brownish, cloudy fluid with a
glistening su1iace scum. Tho scum consisted of
cholesterol crystals. The spcdfic gra\•ity w~s 1.020.
The protein content was high but the sediment containod only u few disintegrating cells. A p•·eli minary pathologic dla&nosis of giant intrn-abdominal
cyst, pr<.>sumobly elf ovarian origin. "'"" made 11nd
laparotomy recommended.
At ope•·atlon, a ku,c, thick walled cyst was found
firmly attached to the anterior abdominal wall, to
the fundus of the uterus and to the terminal ileum.
The cyst m cnsurcd 35 em. in diameter. The tubes
and ovaries were identified nnd found to be entirely normal.
hyalinized connective tissue and numerous
ce~
and rare eosinophils. However, most pl'ominent &re
the large mononucleor phagocyt<.>s and foreign body
giant cells with large llmounts of cytoplasmic golden
b•·own globules which, at times, completely fill the
cell. In addition, the cytoplnsm contains pale, bluish
bl'own material and nuclear debri.s. Occasional
compressed and degenerated smooth muscle nuclei
find fibers a 1·~ seen. 1,hey b1c1·easc In numbe r ln
the deeper layers ol the wall and are disposed in
long and lrnnsverse bands separated by edematous
accllulat·, wavy nnd dolicule acidophilic fibrils.
Fibroblasts also a•·c seen. Scattered th•·oughoul the
section are many large phagocyte;; containing
golden brown globules of pigment in the cytoplasm.
Infiltration by otl1c1· cells is not pru·ticui31·ly promi·
nent. The changes in th<.> blood vessels • .-... sttiking.
The walls of the veins and arteries nee thickened
nncl often the muscuJnris hns been replaced by con·
nc-ctive tissue, which is J1'1'Cgular and simulutcs
nodularity. Masses of relatively acellular, hyalinized or edematous conncctlve tiJsue alternate
with intervening thln at cQs. Since the int.im~ has
t.akc.n part. in this process, the lumen assumes a
"scaUoped" appearance.
My ditlgno$is is a cystic myo6br·amn of the uterus.
Howev'el', purely on a histologic bosls. the diag·
no.ois of this slid<.> would be a cyst wall composed
or smooth muscle with severe vascular changes
and evidenc.e of old hemoJThage. With t],o aid of
the history and the appearance of tho gross speci·
men, one can be a littl<.> bit more specific. The dif.
fctl'Cntia.l cllaf,rnosis, dinicall>'• would have been
asci~s,
etiology unknown, ovarian cystadenoma1
and cysiie myofibroma. The findings AI exploratory
laparotomy excluded the first possibility and the
presence of two not·mal ovories excluded the :;econd. Oval'illn cystomas are 1cneraJiy freely mov-
able because the ovarian ligament fonns the pedicle. They ore not attached to the uterus or to the
sur·l'oundlng structu2·es but lie free in the pol'i·
toneal cavlly. The cystic myofibroml1.S, on the
othe>r hand, arc fixed to the wall of the uterus at
single or multiple points And, at tirncs, also to the
floor of the pelvis. This is an example of the giant
cystic myofibromA of the variety seldom seen today.
Before discussing the pathogenesi• of the cyst, I
might mention that the most commonly accepted
theory as to th<.> histogenesis of the myofibroma is
that they arise from immature muscle cells. These
tumors are most likely to develop during the physiologic and poU1ologic states of the ute•-us when hyperemia OCCUI'S. as in pregnancy and chronic pelvic
DlSCVSSION
inAammalions. They regress during puerperium
Ono SA!'Rln, M.D., Chicago: Tbe scclion (fig. 8)
shows a segment of the cyst wall. tho inner aspect of
which is partly covered by. fibriiJar, acidophilic ma-
and nt menopause when the blood supply decreases.
This patient was opproxilnately 47 yeaxs of age
when her symptoms began. There wos a moderate
tednl, together witll compressed, elongated and
deeply basophilic cells whoso long axes is oriented
arteriosclerosis of the various branches or the
utel'lne a1·tc~·ies and there is o. tremendous artedo-
CL INICAL PATHOLOGIC CON~'E/lENCE
Se Ml oJO M<l{
sc1erosis 1n the s~ction which was shown. One
v;ould hav" expected, according to the previ~us
slatemen!, a regrOSllion ratl1cr than a progresston
in the siuo of the cysL However, one can speculate
lhatat that time the myofibroma bad already estab·
lishcd an accessory blood supply from its extra·
uterine, nnd typically parasitic, attachm~nt ~ the
anterior abdominal wall and to the small tntestin<t•·
With the decrease in the uterine blood supply and
the development of necrosis, areas of degeneration,
and eventually cysts, fot·med. At the periphery,
however, one can sec tJ-aat the blood supply wns
still adequate due to collntcrals, fw'lher corrobo·
'
"" "
""Jifn r.<.<i< 0<.G
B,
D ye.get·nllno ma
HWory.-(Presented by J. 0. Boley, M.D., Uni·
vct'Sity of Kansas Med;cal School, Kansas City,
Kansas). This 27 year old white man had always
had cryptorchidism (intra-abdominal). In Fcbru·
ary 19·17 the patient suffered multiple fractures of
the right clavicle and ribs with apparent puncture
of the right lung. In addition, an emergency splencctomy was performed for rupture of the spleen. Our·
ing hi!! hospital stay a diagnosis of moderately ad·
vanced pulmonary tuberculosis was made and he
wns tt'.Ansferred to a sanitarium. Shorlly after that,
he noted a palpable l ump in the dght groin. It
could be displaced in to the abdom en and was Inter·
mltlcntly pninful In May of 1949, bccaUBc of lnCt'CU!iih."'lg puin, U1e mas.r; was excised.
The testis measut'ed 6 by 4 by 2.5 em. The pnrcn·
chymu uboul the hilus was •·cplaced by conAucnt
nodules of ycllowish gray tissue. The cut surface
bulged markedly.
DISCUSSION
OTro SAPIWI. M.D., Chidlgo: Examination or the
microscopic section (fig. 9) reveals that this is a tu·
mor of the testis. Attached to one margin arc the
ductull effercntcs. Tbe testis is largely replaced by
sheets. small columns and alveoli of tumor cells,
soptu·ated by a var·ying amount o£ connective tissue
infillt·ll~ by small numbers of lymphocytes. The
cells vru·y some\vhat in size, shape and, in genera l,
tll'C qu it.c large. They at:e l'ound to polyhedrtl l with
FIJI. 8, 1111nned out muJWic ilbcrs ond se ver~ des::-e nerativc
chan~ea..
rated by the beautifully p reserved large and <mall
muscle fibc1·s.
Sections of tl>e cyst wall, stained according to
the van Cieson method, show necrosis and cyst
fonnation. There are some areas of hemorrhage and,
at one margin. lnwct smooth muscle fibers.
LEO Lowettn. M.D., Tulsa,; I would like to have
your opinion as to the origin of this tremendous
amount of fluid. Is it a p1'0duct of granulation
tissue !rom the lining o( the cystic tumor, or is it
related to the severe obliterating process fou nd in
the blood vessels? We still hove the pt-oblem of explaining the orialn of about 16,000 cc. of J\uid. It
seems to be un intorosUng phenomenon.
DR. SAPIIln: It would seem likely that the fluid
"'as not the 1·csult o£ un exudation but was much
more likely a u·ansu.luto. Ther<' m ust nave been
tremendous compression of veins and lymphatics.
1n all the textbooks of patl1ology and gynecology,
one finds a n umber ol descriptions of this type. I
can not recall ever having seen such a large cyst.
I have seen hugo ovarian cysts. cysts as the result
o! hemorrhagic necrosis of the pancreas filling the
peritoneum, and one instance of a huge, primary
cystic tumor of the kidney. But I have never seen
a cystic tumor or this sorL All agree. then, that this
is a cystic myofibroma.
t~I(C. 1), Oytgcrmlnom.a.
(IUIIJlty Ol th• n \lt JOI.
Note the v;trio'lUOI\ ln tho l lnlnhl[l
disUnct cell boundud~s. The cytophtsm is pnle, clcn1·
or fintCiy granulru·. The nuclei are large wiLh ccnt•·nl
nnd llfOminent nucleoli. The chromatin is fine and
•·cllculated with thickening at the interstices. Nu·
mc1·ous mitotic figures are seen. At the periphery,
rus well us scattered throughout the tumor, are
atrophic seminiferous tubules and masses of libt'Ous
tissue which may represent fibrous replacement of
tubules. This is suggestiv<> especially since some
of the masses form one margin of the atrophic
tubules.
TC!irll ~
CLINieAL PATHOL OGIC CONFERENG:E
ht on.e area, wl1l<:h appcru-s to be cor pus higll- experience botll embryonal. carcinomas or teratomoriJ ~ere are irxegular tubuhu: stru¢tures lined carcinomas may contain feaf\lre-$ of dy.s gcrminomas.
by columna>· and c ul:ioidal cells with n brush)>ordru·.
At Michae:l Reese ,Hospit(ll we d iagnose embt}rSome of these arc replaced by tumor cells. Tbin onal carcinoma, teratoma and teratocru·cinoma on
bands of connective tissue cont..1.in ing blood vessels n\re occasions. \Ve try to differentiate between a
furthe~; subdLvide U1e turno•· into lobules. The1·e
seminoma, a tnOl'e mat ure and more benign tumor
js little necr~i s. In addition, one s~es g-t·anuloma ta composed of cells 'resembling cer tain spermato·
co m)>os~d of cot1centrkally arranged fibrous tissue1
g,enia, a.nd dysger.m inoma, a more immatUJ·e · and
epithclioid cells and a few h·mphocytes and p eriph- mor·e malignant tumor composed of- cells which re-.
e.raJ iy situated ghmt cells of the Langlums variety semble t he primordial germ cells.
(fig. lO) .
The granulomas and giant ¢ells wel'£1 dfr.Scribcd
ThiS- twno1· is a dysg~rminoma, of the lestis. In b~ Friedman a.n d Moore in 1946. They statell that
view of the clinical diagnosis of a modet·ately ad- "giant cells of the foreign body and L nngbans type
vanced pulmonary tuhc1·culosis, and in the presence were common in the .p eculiar st:roma of many semof granulornas ·in the tum.<u·, one might be tempted ino!l'las-." These gran ulomas are aJso (ound in the
t o add another diagnosjs: narnely, tube1·culoos dysg~rminomas or the ovary.
gn~nuJomas of the testis. l'Iowevel", F1·ied man atld
In these photomic.l'ographs it js evident th(\t this
fvlooret have described theb· frequent occurren<:e is a malignnnt tumor. The c:eUs beat a s triking re·
in dysgenninomas. I think that !J1e greatest diffi- semblance to the pl'imon:Hal ceBs. ·They vary conculty in this c.-1.se lies i n apper)cfing a name to this siderably in size~ sh ap e and sta.i ning quality. They
huno1-.
ate arranged in sheets and small col-umns separated
It mi"ght he helpfuL. at. t his poin t, to J'eview some by a variable amount of connective tlss.u e and in·
o f t}~e clas~ificn tions or testicular tumors which filtrated by small lymphocytes. In !Ius section there
"have appeat·ed in the literat ure. Ewing~· s sub ~ are severa] granulomas w ith large giant, cells, This
d ivided the testicular tumors into tJ,.ee types: (1) aJ•ea 1'csembles an embryonal ca,·ci.noma, present..
adult embt·yoma or t~ratoma; (2) embryojd, tent- ing the ptoblem oi whether this is a dysge.rminomfl
toidt or nlLxed tumors and (3) embryonal mali:g- in a~Sociat.ion v.1ith embryonal carcinoma. In connant tumors. Twombly·' simplified it and presented tnlst. thh; slide o[ mY collection is 1·epresentative of
only two types, namely; seminomas and teratomD.~. n scminotnil. 'l'he ct'!lls al'e uniform and under h igh·
Karsnet5 divided these tumors in to emb1·yogcn i c er ma_ihification resell)ble ce.t·~ain ~p~rmatogonia.
In sUL11mary, I would calJ this turnor a "dysgert<II'!\OI"S, te1·atomas, undiffe1·entiated and partly differentiated tumors, seminomas, embryonal carci- - minoma,'' meaning u t umo(' ~nising ft·om gotladal
nomas-and choriocarcinomas-. Friedman and Mool'e cells which are not differentiated. I t is, therefore,
d ifferentiated t hem into four group$:: (1) semi .. more malignant and has great.et· potentialities than
noma or' ge.r rninoma: (2) ernbryonfll carcinoma wrth a seminoma. On Ole other hand1 the latter is more
cho1·ionepithe-Homas ns asltbdiyision; (3) teratoma, d ifferentiated a.nd the morphologic picture is more
and {4) teratocru:cinoma. The interstitial t umol's uniform. Clinically, it is not. quite as maJ-ignant a~
have n ot been included in these series. It is q uite t he dysgerminoma.
ROB£R'r MOORE, MD., St. Louis: It is true tbat
appm·ent that thet·e is considerable diffc.r cllce Of
opinion. Chevassu called such tumors uscminomc" there is a. type ()f tumor of the testis which on one
because tl1ey bore an exact t·esemblance. he occasion I call a seminoma and, on. another, I call
thought~ to ce1·tain spenn.atogouJa in the deeper an embryonal carcinoma. Dr. Ft'ie(,lman fc-e1s that
layers of t11e tubules. Twombly, I believe, would in this type .o f h.tmOl' -the anaplasia and abnormality
have called this tumor a ~eminoma. Ewing wouJd o£ t11e cells rep resent artefacts in the pl.'eparation of
hove called it on embryom~, of which seminoma is the sections. I am not in agr~ment with him on
a subdiv is ion. He fe.Jt that it arose l':rotn U1e r~te !his poil1t I think that this is· a distinctive type of
testis, rat he..a· than .&·om spe1·matobhtsts, and that tum<1r. r have not as yet given it a name such aS
the !$emjniJerous tubt.Ues either b~came atxophic or you have-dysgerminoma. Is the p1·ognosis in this
wer·e second1;1rily invaded by tu mor. K arsner agrees type of tumor d ifferent fr om that seen in the or-w ith . him . However~ 'Vlllis'' d isagrees and stales dinary seminoma·! De. Dixon. is fo Uowi.ng these pa:
t.hat uthere is p rogt·essive neoplastic change in tb e tients. I am awaiting his conclusions. In the lantem
se111,inal -e pithelium.' ' He does not feel that they slides from this case, I called the first a.n embryonal
arise fl'om em·ly celh. Both he and ..tu'lderson1 carcinoma. However, in the la$t photonticrogt·a.ph
would have called such a tumo1· a seminoma. 'B'ried- it looked 1ike a se minoma. ThJs is the type o.£ tumor
man and Moore) ~( I may guess, would prefer tl~e whjch contains characteristics oi both, 'Whether it
term ~:get·minOrn.a!l ol· "dysgerminoma" oil the basis represents another type: ox: whether it .is a wu-jety
that the cell of origin is the primordjal gc.r m cell. of s.eminoma wi th the same clinicol cow-se, will de·
As you kno\\'1 they p1'esented 922 tumors oF the pend on the results of tho follow-up stuc)y conducted by Dr. D ixon. He is observing the CQm·se jn
testes~ of which 35 per ce-nt were dysge1·minom.as1
or~ seminomas. Interestingly ¢ nough~ they found
900 men \vh:o deveiOtJed testicular tumors while in
seminomatous areas in 20 per cent of the embry - the Army.
onal carcinomas and in teratocarcinomas. In .tlieil'
LAilREN V. AcKERMAN, MD.. St. Louis: · I call~d
CLINICAL P,\ T HOLOG/C CONFERENCE:
this 1umor a seminoma, and I agree wUh Dr. ?\;loore
that follow-up Is extremely important. Equally signll\canl is the respon.•e o! these lesions to
amdlalion. We know that it does nol make too
:nueh difference wha.t the lc.rminology is as long as
it is known thnl the tenn uscminomau mean.co a tu·
mor with n b<>tter prognoois than practically all
the res! of lhe le$tlcul8r IUffiOl'S with the <>l<CCption
of the well dlfTerentlated teratomas. I believe thnt
follow-up l.s going to be helpful.
Q. J. DIXON, M.D., SL. Louis: A1though I thought
that this was a seminoma, I was uot certain. One
sees al{ vuriution~ In the t wo slides shown. As a
matter 9f fact, tho l:JI'nnulonmtou:; replacem ent may
be rnor() advrmccd thnn is fow1d in th is c.ase. I t m.ay
progres• u11lll smnll g a·oups of single tu moa· cells
~..;..-.,' ~~.,.~· ~7 :.. ;'"""'...-~ '<:ti..;jZ.~
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4.~
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,
-<;',i '... ~.,, ,,:-; ' " :- .·~e.~·~ . ~ J-~ . ,,,
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· ,~•;,,>:1:r~::"-~,;\~'}rt{'.$:'-'-'""-".(~·f~
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And~rton,
co.. 10•&.
W. A. 0 .: PathotoJOr, St. Louil. C. V. MOib)'
q,
f!~U611AVf L'IMI~OIJ<\ VS,
t.£0"-E.t<li\
Lcukosru·collUJ
Historu.-(Prese~~tcd by Matk C. Wheelock,
:\t.D., Passo"nnl Memorial Hospital, Chicago) . This
5-~ year old mnn entered the hospital because of
bllatcrol enlargement of the testes. Attention wns
called t.o this by n dragging sensation in his scrotum.
ExploraUnn operation and biopsy were performed
on both sides. There -w ere immature cells in the
periphet·eJ smear. suggestive o Fan aleukemic le ukemia (tolal while count 4,800) . Fo rmal bone mnn·ow
biop.•y (sternum) showed t umo•·.
orscossiO_N
0T"ro
i~ an
SAPHl R,
M.D., Ch icago: hwadlng the
te~Us
extremely \:C11ular tumor arranged inn syncy·
tlun'l. Vnrlutlon in the size and appe;:u·ancc of t.he
c~lls I• apparent (figs. 11 md 12). The connective
Ussuo Is present as a delicate network. Vasculnri7"''\•
lion Is foirly l'ich nnd is in the form of smnll blood
vcss<':ls, the- walls of which are ofien oontinuous wUh
the surrounding connective tissue. The cells nresomcwlml pleomorphic with sparse. often deeply
acidophilic, cytoplasm. The nuclei are rcni(onn or
polyhedral. The chromal.ln is usually eonrscly
grunulnr bul. at times, is reticulated or condensed
a t the periphery. !\'lito tic figures ru·e present. Diverse chungcs ln the seminilerous tubules arc v•·cs·
•.A: \ ~"'"'
'1, ,, . .....
_ .v
. ...
• t.,'l
'••~ ~ · ..-:.,
~-"'
FIR· lG. Oya~ermlt,omo. Note t he granulomatous lc;sl<m nnd
ihe tuznor e~llt ~d.Jnc;MI to H..
a<e complclely isolutcd by granulomatOus tissue. 1
ha\•e not much to say about naming it. at present;
I do not think it. desc•·vcs a special name. I may
ihink dlfTcrcnLiy, of course. when we have the
follow-up data on our cases. In going over a series
of 300 or 400 seminomas I hnve found no morphologic criteria which would enoble me to make a distinction and say that there are -reallv two types. ll
is prelernblc, 1 believe, to group nfi these tumors
as seminomAs and perhf'ps note gt·adation of ch ange
wilhin the g •·oup. Dl'. Saue r and associates repo•'led
a much bcltot· pl'ognosis in seminomas w'th
lymphoid infi llrnUon tht:l n in U"tosa wiU1out. The
greater lh c lymph oid Infiltration was. the better
was lh!! pl'OJnosis.
"
On. SAMUJt: Of coU •·sc, follow-up is as significant
as morphologic e)u$1llficnl ion. Whatever the nome!\•
clature mAy b4:, the fmnl course of the p atient is
important.
J. Frll'dm.an. N. B .• rtnd. Moore. B. A .: Tumor$ o r Testa:
an 922 CPMI. Mllttary Su.qt. 99 :S'i3-i93. 1946.
- P:winl- J , : Tetraiom~ T~ and lls Derh·ath·('S. Surg.,
Cyntre. & Ot.t. t:I: ZH-461. 1,11.
1. Ewl~ J .: Neopl111tie Di~USes. PhDaddphl~. W. B. Saun·
dtrs, J~.
11. Twombly. G. II .~ Rto:loUo ruhip of HQC1T10n~ to Testirulat
'!limen<. sur....,. >O: tBI-190. ,..._
.S.. itarPIU. H. T.: lluma.n Pathology. PhUadelphla , J. S..
Upptncon Co•• 19-49.
G: \V11ll$. R. A.: Palholoey of T\lmors. St. Louis. C. V. Mosby
R~
co..
1~8.
l)<'ly. II , Ltukonrcoma. Note th!! dil'tU..!IC lnilltrntion ot IUmOr
cc Is a 11d lh4: prtki'V:ltlon of tcstict•laT tul)U!es •
c nt. S i)OI'mntogenesis is absent. In many tubul~s
Lhoa·o is invasion of the basement membrnnc. In
oUto•·s, clospito almost complete rcplaccm~nl.. or the
tubules. occosion al Sertoli eeUs can be idcnlifi~d.
My Ci1·st impression in ihis case was that this
was a lyn1phosarcoma: oi the testis. How~v~r. it is
difficult to dUferentiate between a lymphosarcoma
and n leukemic infiltn:~lion . In contradistinction to
the p•·cvious case. there are many atrophic tubules,
so m11ny that the organ can be identified easily. This
is nn impor ta.nt fealure in the differential dingnosis.
Th~ cells which arc seen invading the ti.s.•ue between tlac tubules"'" mainly round cells with llLUc
CLIN/C.4L PATHOLOGIC CONFERENCE
variation in size, shape and staining quality. The
nuclei al'c hyperchromatic with either coarse o r
fine clu·omntin. The d iffercntinl di11gnosis rests between h rmphosat'coma and lcultemic fnfilt1'.nHon.
Clinically, both testes wo•·o involved. The total
whitt! count was 4,800 and immature white cells
were. present in the pe1·iphcrol blood smear. A bone
marrow biopsy was thought to be diagn051ic o{
Jymphosnrcoma. From the information at my disposal and from Lhe sections, ( believe that we nre
dealing with an aleukemic lyntphadenosis, O l' liiU'coleukosis, a moJ'e prefcl'oblo term. By sarcolcu..
kosiS1 I m«!nn a primary lcukcrn.ia, with aggl'·essive
qualiti.,. of the leukemic infiltrations. In conl.radis·
tinction, and 1 am introducins anothe.r tenn for the
SPke Q( cJnrily, leukosarcoma i$ a separate entity,
It is primnrlly a sarcoma wilh invasion of the circulating blnod l.*nd the produclion of a picture Kimu·
.l uting l~ukemia. St~1·ilbcl'g, who originally inll'O·
duced th~ term "leukosru·cotna/ 1 meant a pl'imary
Jeuk<>mia with leukemic infiltrations that had tumorous Characteristics rather than a primary sarcoma. For this reason these tc1ms have been used
three cnscs developed simultaneous, bilateral tcs·
ticular involvement following regression o f the pri·
mary tumot· in the nasophnrynx. There 91'C only a
few ca<cs of this type r epo•·tcd in the li te•·ntut·e. It
is inlct·csting that the testicular tumor appeared
while the nasopharyngeal tumor disappea••cd or
regressed following irradiation.
Shortly before Ibis conference Dr. Wheelock in·
fonned me that Ibis patient had di«<. After reviewing the socLions of the liver and spleen, I thought
that the P•llient had plnsmtl cell myelomu. This
does comp iIcute the issue! Of coul·se, tl1ere is u tela~
tionshi;> between these two diseases. But, I still con·
not see pla:sma cells in th~ testis. What is more in·
teresting, howevert is that someone here made the
diagnosis of plasma eeU myeloma from the sectioo.s
of the tcslls.
RoBEI!T MooRe, lVI.D., St. Louls: I was told that
I looked ut this slide last J uly and said thut I did
not believe that it conl:aiMd ony teratoid elements
or was a seminoma. It docs not belong to any category of lumors that I know.
M. C. Wtw:LocK, M.D., Chicago: D r. Friedman
saw it and called i t a lymphosarcoma. Thls man
did have x·•·ay and nitrogen mus tard therapy before
ho clied which, I tltink, mc•·cly hastened the cou•·se.
In add ition, the serum pro toins wer e not clcvuted
and there was no Bence~Jones protein.
DR. SAPKlR: If I remembo.r correctly, lhe Bence·
Jones protftn test is posiUvo in about 60 per cent
of the cases of myeloma.
I. Mntht'l. c . P.: Lyrnpbosarcornra of
a Cnse, J . l,Jt•ol. 5S : 530-5U, l!loiG.
th~
'l'tst!e!t. Ueport of
O(lckcrty, M. B., and Pr lestloy, J . T. : Lymphon.~u·c:nmt~ of
Testls. Report. or Jl"out' New Crase,, J . Urol. 4S: S14-ll2:t, 1M2.
3. Colby, F. li.: Lymphosart!omn Clf BoUt Tc~Ueles MetuUtUe
From NBSOplHU')'PX. N~· Enlt)and J , Med. 202 :SS7, 19:10,
4. Wat~n . &. At.; Sauer. H. R .• and S..du,sor. M. C.: M&.ni·
festatiocu ol tM t...vmDhobtastomas In the Cenilourirml')' Tract.
J. Urol 01 :621·6U. fs.t9.
:!.
FJa. tz. SlmUar fh:ld- h1gh m.agnifi't<&lion.
10, Carcinoma in Situ
interchangeably and the litera ture is confusing.
Leukemic infiltl'ations in 1hc gonads oceu1· moTe
often than suspected. We have studied ninoty·llve
cases of lcuk<>mia of which iS per cent were children. The s onads were involved in thirteen cases,
in six of which th~ leukemic infiltrations had as·
sumed aggt·C$Siv<> properties. both\in the testis and
i:n other Ol'guns, with tJ1e formation of tumors. Ona
of these wus n chlorosarcomn. or chloroma. 'Mulhel
in 1946, swt«< that lymphos.~rcomas o f the testis ••..,
rare. He reported one in a male 63 years of ago. It
was a unilateral tumor. He stressed that there is no
lymphndcnold tissue in the normal testis; bowover,
H;slo'lJ· -( P resented by R. E . J ohnson, M.D.,
Ellis E'ischcl State Cancer Hospital, Columbia) .
This 45 yea•· old Negro womon gave a history of a
slowly increasing abdominal mass for three and
one hall yeurs. Examination revealed a large, lobu·
]ated., movable tumor in th~ lower abdomen, nppar·
ently arising from the pelvis. A biopsy of tho cctvix
was intcl'preted as epich~1·moJd carcinoma. A p1-ln·
hysterectomy was performed. The secUons arc £rom
the surgJco.l specimen. The patienl received t rans·
vaginal roentgentherapy postoperatively.
a primru·y £ocus may occasionally exist on lho bt1.sl.s
o f an old inJitu·nrnntion.
Ol'To SAPilm, M.D., Chicago: Sharply dcllmited
Dockerty nnd Priestley' found four ]ymphosu,·co-·
mas in a gr oup of 400 ~ticul ar tumors. Colby• presented one instance o£ mct.'\St.:lses to both testes in
a patient with primary lymphosarcoma in tltc nuo·
pharynx. Recently Walcton nnd coworkersi presented three cases of testiculor involvement. In two
Lherc wns u lympho~arcomn of the testis and in one
the.~·e wus only leu.kemic. infiltration. Two o f th ese
DISCUSSlON
from tho ondoccrvic.al mucosa ana appeadng to be
multifoculln origin, are areas of squamous cpithel·
ium noticeably increased in thickness (fig. !3). The
sequential nnd orderly layering of the epithelium
is disrupted and tht> basal layers are the seat of in·
creased activity. The usual perpendicular nrrnnge·
ment of the bawl nuclei is replaced by parallel •md
angulus· ru·1·1mgement producjng a disordcl"ly picture. The prickle celllayct· l$ incrensed in thickness
and although the nuclei of the cornified layer. arc
el0ngated and b:,<pe!·cbromatic they are preserved.
The rete. pegs. are wide~ than usual. The cells arc
large; oval Ol' po1yhedr..al with little gt·anular .ucidophillc cytoplusm and large 1·ound or oval nuclei
which vary considerably in size. :M any are sepn1.:ated
from the surrounding cytOplasm by clear bal0s.
There are nwnerous large pale cellS ''.rith bi7.ar:.r e
mitotic figw·es. Focal intercellular 'edema causes ac-
centuat;..on of the cellulru· membranes. Atypical
mitotic fig.o-u·es ru·e seen 1requently in a ll layers o£
the epiU1elium. The ~utter is often _seen extending
along the ducts, either Wldermining or growing
above the epithelium. Similar changes arc seen in
the glands.
, •
My diafP10Sis 1s carcinom~ in situ. Ordinarily, I
avoid tills term ~s well as adenoma malignum
and fll'einvasive ca1·cinoma because. oi the uncertainty which these terms provoke. fn this i nstance,
the diagnosis is based pu•·ely o.n cytologic or mor·
phologic e_,y-idencc. There is distinct anaplas'ia, anachromasia and many atypical mitotic figures, but rio
invasion. aowcvel', io some fields, the latter js simulated by tho normal "dips" of the mucosa.
Is one justified in calling a tumor which is not
invasi\'e a carcinoma? Is not infiltrative growth one
of the most iinportant motphologic character-istics
of ca1·cinoma '! On the othct hand, ooe knows that
there arc obvious1y benign tumo.rs "vhich are invasive: neurofibromas, certain blood vessel tumors
and nevi, The Q,ues'tion also arises whether or not
e.ve!;Y (!arcinoma in. situ.. if untreated, will develop
iiltQaD invasive carcil}.oma; whether~ if it is a special
entity, assumi_n g this pal·Hcular histologic state, will
t•emain uin. situ" inde6nitely. Up to a period ending
two·_years ago, we examined 1!717 cervices, of which
only eight \Nere called cat:cinoina in situ. Pund and
coworke1·sl in a. more recent communication maint..atned that· in.cipient cancer of the cervbc uteri is
usually not invasive, implying that every c.ancer
ol Ul.e ctn·vix begau as a preinvasive cancet· 0 1· t'l$
a carcinoma in. situ. Galvin and TcLindea recently
concluded that if carci11oma in stt·u. is found jtshould
lie- c~nsidered strictly a historbgic diagnosis and
three possihiliti"!' should be considered: (I) the
biopsy was taken from the poriph<>!·y o.En.n advanced
cervical cancer; (2) microscopic evidence of invasive cancer is present eJs-ewhe..re in the cervix,
and (3) carcinoma i1t situ js present only and no
invasion has yet taken pJ~ce. They l'ecoo:Unend a
modified Wertheim operation with pre.sel'vation of
one oVary in-youngcn" women, o·r extensive radiatiorl t;reatment. I consiaer t.h:is an impoxhmt problem. The term carcinoma itt situ means that there
are eplthelial changes whic.h_morphologically resemble those ~et':>n in a cm·cinuma but without i nvasion. I do not believe tl>at it is an eal'ly "full·
fledged1' car cinonta.
It ls sometimes difficult. to resh·ain a gynecologist
from tloing radical suSet~y~ once he receives a diag~
nosis of "cat·cinomau jt"J·e,spective of whether it is
ca1led "in sit·u/' Ot' 11 invasive:' 1 I received a biopsy
of the cervix of a· young woman who was 26 years
of age and in he.- sixth month of pregnancy. The
biopsy disclosed the presence of a typical carcinoma
in. si.t u. I appHcil all my art of persuasion to prevent
an o)>erat.iv.e procedure. The gynecologiSt agreed
to follow the patient with smears and biopsies at
regula1· intervals. That was about two yeat·s ago.
The patient w.a,.s delivered of a n ormal infant and
her subsequent course has been uneventful.
About a ye~u· and a half a·go, it was ·my privilege
to be- invited to the 1.·ound table discussion given by
the American Cal).cer Society to discuss the value
of cyt9logy, in pa.:ticulnr the val ue of sinem· diag·
n·osiso of ce•·vical and uterine lesion.~. One of the
lengthiest discussions was on cm·cinomas in situ.
TeLinde was present. Despite a long and heated dis·
cussioo, we were unable to agree.
It is impossible to predict the outcome of car-
.
: .::-
••
-
•.:/
Flc. J3. Carctnoma l n !l.i{U <>f the
c~rvix.
cin01na in siiu, particularly when the biologic ac
tivity is unkno\vn. The latter can be determined
only in living patient;;. All d•·ead assuming the re·
sp-onsibiJity o{ uwatchful waiting." Equi;'llly unsatis·
factor)' is the mult.ilating panhysterectomy.l?ethaps
I exx on the side of consc.r vation, but 1 am quoting
from my experience which. admittedly, is limited.
JoaN J . .MooLIN1 M.D., Columbia: Dr. Saphit·, how
many cases of carcinoma itt sit:u. hav~ -you seen and
4
lollow~d'
DR. SAPtJm: Well, I cannot answer that question
with any degree ·of accw·acy bccause 1 with the ex-
ception of the one case to which I have alluded, all
others have been su-bjc·cted to -surgery,
Ro:nER'f MooRE, M.D., S t. Louis: l do not know
what I would do. I have had a good deal of re.sist·
ance again::;t the whole conqept o£ carcinoma in. situ..
I think it is fair to say .that I was just about •·eady
to accept the Mea un!,il I had th.e opportunity about
two years ago to see a series. of slides of cervices
C1·om pl'egnant women. In this series there was one
example of carcinoma in situ, but the cer.vi.x rc·
v~rted to nofmaJ after delivery. Thus, my ~·esistance
against the diagnosis of carcinoma.in situ. is building up again, particularly since it is known that
hormones can p1·oduce a change in the cervical epi·
CLINICAL PATIIOLOGIC CONF&RENCE
th_cUum which is entirely l'Cvcrsible a nd which has
LAuREN V. AcKF.RMi\N1 M.D., St. Louis: May I sa)'
been c.nlled carcinoma in. sh11..
th ink this Jos.ion, a l5o, is over diagnosed. I have
DR. SAPRIR: Fot• the lasl two years we have even seen examples of squamous metaplasia of the
studied .changes in the cervix in normal pregnan- ceJ'Vix reproduced in • medical journ.1l, labelled as
cies without seeing changes s uch n~ yo u have d e- cm·cinoma nnd ope:rntion pedorm(!d~ lt was not
scribed .
CM'ci.noma ot nU. Seeon~ I U1ink it impel'ulive thnt
DR. MOORE: I was referring to a series studied by if a cervical biopsy contains an i11 situ eat·cinoma,
Dr. Hellman at Johns Hopkins. Biopsies were taken. curetlements should be done to del~rmine ' "betber
in a systematic.: fash ion dul'lng prcgnn.ncy and (I rtet' o1· not th ere is invasion in some other i'H'e8 . And,
deliveJ'y. In tl1nt sedes tll(:t·o was one carcin oma flna.J.Jy, I think i l ii is going to be a qu estion o£ treutin. s.it1l and t-.vo or three othecs about which I wns a mtnt one should consider irradJntion thcrap~'· The
litt le hesitant. However. I underst.1nd Dr. TeLind" uterus nor the ovaries would be removed and transthough L they wN'O car cinoma i n. Ritu.
vaginal x·roy t herapy would not stel'ili7.e the- pa·
B£Nnv Pn<RP.llTON, M.D., SL Louis: l believe thot ticnt. It is import a nt that p a thologists in hospitals
changes like this can be produced experimentally with a large volume of old mnterial, r~view tlte
by estrogens. Some physicinnS continue giving ~a.ses of carcinoma in. situ, and find out what hapestrogens and d o Pnpan i<:oluou stains un til th ey fmd pened to lhose pat.ic, ts. If tl>cse pati<nts are no\
some malignant looking cells. I do know o£ al lc ust tr cnted! and one .is quite convinced that there is no
one case in which n woman bud a definite carcinoma in\'Mion after curettcmenl then a ciu-eful follow·
In sittt and later hml one not·mal child. Two or three up for many years must be done. This group will
y ears la lOJ", following hystt•·ectomy , the carcinoma p •·ovid e us w ith the natu ral evolution or cnrcinoma
was still present ond was s till in sit u.. The d iffioulty
in. sttu.
Hes, I think. in dctc1mining how long the carclnoM. P mso" NEAL, M.D ., Columb ia: AL the Uni·
ma hru: been prt'Scnt. I believe thenl is an opinion vcrsity of :\1issouri, the late Dr. Edgar Allen and
that it remains ·h a. situ for ~oven o r eight years, b u t h iff. associa tes, in an atte mp t t o pt·oducc C:Ol-cinoma
eventually invades. li a woman has hod one 01' two o£ t he. ce1-vix in m.on k~ys, gnve J'cpeatcd estrogen
children. reaches tl>e age of 40 or 42, and still h <JS injections over a long period
time. Jn addition,
c:~rcinomn in- s-iru, it seems prudent to do a hysterec-the lip of the cervix was traumalized by multiplo
tomy.
_ and repeated incisions. S ections o r the cervicc~ were
Dn. SAPHlR: Whut wou ld you cflll such lesions than see~ by a numbl!l' of pathoJog i.sts in the central
that arc produced expe rimentally?
stntes area nnd none could call them cm·clnoma. In
M. c. W HEELOCK, M.D., Chicago: r would like t o some sections there was a growth of epithelium
menlion a few cases wb.ic.h h ave been obset·ved a t into the incised foci such as i$ frequ e ntly se-en in
Norih wcstem and at related h ospituls. A biop•y of shn ilur dipping of epitlu~Hu m into cuts
vascular
the CCI'ViX of a pregnant \VOJnaJ) Wsciosed the p i'CS· tissue, fo r e xa m-ple U1e cornea. The ma terial was
ence of n p reinvasive c~rcinorna. A hy$~rectomy seen by a pathologist in New York City who saUl,
was p o•·!ol'med end serial sec t"ion.s o~ the cet·vix "IC I have to give an opinion, 1 would call som ~ of
showed invasion. This w As, of course, b~yond Lhc these carcinoma." The monkey8 we.rc kept ov~.r :.
stage o£ carcinoma in sUu. About two yeal's ngo I prolonged period of time, some of U1om d ied of
saw a similar case at the University Hospital in senile changes or tube•-.: ulosis, bul not one of them
Iowa City, w h ich was c:alled carcinoma in situ. showed an in vasive neoplasm or metastases.
Nothing was done und1 with in less thun 11 year, Ute
RuTH S rcot noF.nc, M.D., SL. Louis; '£hoso expeo·i·
woman had advanced carcinoJ1lll of the cer vix. On ments were published Jast y ear in Cancer Reseaych,
the othe•· hand . a woman in the Clinic of Northwest- 8:81, 1948 by Dr. Carol! A. Ffellfer, one of the col·
em Med ical School h ad been seen at S t. Luke's Hos - lubo rntors o f Dr. Alle n . The response of Lhese mon·
p itnl nboul sLxtecn years before. A t·cvicw of the keys to ~strogenic h•eal mcnt was repor ted as negn·
slides revealed • picture compatablc with a diagnosis of carcinoma in situ, although this was not the tlve as far as the production of cancer was COl\•
Ol'igina l d iagnosl$. Subsequent ccr vicul b iopsies cer.ned. Certain p roliferative chang~ were obtak en uccol'ding lo the I'«:OmJ.Ile ndcd tec:hnic of !-iCI'ved, but. Lhcy were I'Cvers~blc and not maUgnant.
RicHARD E. JORNSON, M.D., Columbiu : I have
Foote und StewarL h ave fnilecl to disclose any
changes. Tbe'gynccol&gistS have done " number of found it ralher confusing to compare the 1-elative
h ysterectomies on patients with d iagnosis o f carci- in.stances of clinically maDi fc-st carcinoma of the
nomas ita. situ. In l"Outine scctlon s of tho e n tit·e ce rvj x COI'vix w ith the insta nces re po1·tcd in fnhly large
they hnve found a numbCJ' with definite invnsiv t! scrios. Pund IUld Au erbach iound the r~Uon of=·earclnoma. Hertig and his group at Boston are in the cinoma. i-n .sicu. and clinically manifest carcinoma
p l'OCCSS of followi ng a sedos of unLrcated cases of
of i he cervi x: to be somethin g like one hundred to
carcinohl u i11. sit1t, They tt1'C going to ~ee ,,,hnt wi ll
one. P er haps there is sDmething t.o th e: idea tl1at n ot
happen in the co~trsc of the coming years.
DR. SAPHIR: Of course, errors can C~CC:ur in tbe all of these. or perhaps none o f U1em. if ono is r eally
occasionul cases und col'l'oborate TcLiude's Mnte- correct in his diagnosis. actually progrMS from the
men L th ut u-,e sections m ay have been taken from ~rcinomn il• .situ slrt$C to clinically manifest carcinoma. Cc1·tujnly som~ e;cpla nat ion is needed Cot
the periphery of ll r egulaJ· carcinomo.
or
or
Cl.Jil'IICAL. P"'THOLOGIC CONf'ERSNCS
that marked discrepancy in incidence of the two
t.sions.
1. PUnd. E R.: NetUH. J . B.; Cald-.·~ll J . D .• •nd !oWiebuf"CS;:
H & · Pnoanvulvt: and tn,·asive C8retnotm1 of Cft'Vlx Uteri.
P;tM)gendl•. l)et.ectlon. Dlifer'(!nti-.1. Dlagnoe;IJ and Pllt.bOiode
Ba£ls for Mant.RC!:tru!:Ot. Am. J. Obst-. & Qynee.. IS~ :831·837 · IW4.8.
'2. Oalvl.r\, Q,A. •• und TeLinde. R. W.: TI\e Pruent-dn)' StalUS
or J\oni nvn~lve cervical Cn;n:luom.a, Am. J, o~. & Gynee..
OT· ts·IWI, ~~>
" " "'"-'
'
CAllin"lc
o-..r· o....,~,.,,{ov
,..,...,....,.
11.
cu•·ofih:rosarcotuu, Re-cur•·en t
Hist.oTu.- (Presented by Mllton Kannerstcin,
M.D.. Vctc1·nn r. Nospit.al, St. Louis). F ifteen years
ago a 72 year old white man first noticed • lesion of
the lower lip. He consulted his physician and was
tmtted with radium; the diagnosis made at that
time is not known. In 1942 he was treated at another
bospitul with irradiation for a lesion said to be
squamous ec11 carcinoma of the left lo,ver lip. In
1945 0>1$ )C$lon was e>:cised at a thil'd hospil:ll, and
tbesnmc dingnosis made. In Apl'il oll948 he ~ntcred
tbe VctOI'tmS Hospital because of a smoll lump at
the ~ito or th e scar . Excision was pctforrnccl and
lbe wound healed prompUy. Sections lnllod l n l' Cveal uny cvidon'ce of neoplasm. There wore no pal..
pable nodca in the area of lymphatic droinage.
In J une of 1949 the patient returned for followup, and o c.rnylsh, finn lesion wa.s noted in the midportion of the low<>r lip which, on biopsy, showed
tumor. A V excision of the area wa.~ performed. together with a bilateral suprahyoid neck dis~on.
In the resected speeimen, on the antcrosuperJor aspect al upproxlmtttcly the vermilion border, there
was a Jeslon which projected 3 mm. above the tldjacenl. lip surfnce. The ov.,erlying epithelium ap·
peared roughened. Cross section revealed n sharply
defined nodule approximately 7 mm. in diameter
which appeared to lie beneath the •kin and mucosa
and to c.~tend into the depths of the lip. Sections of
many lymph nodes from the neck disseclion showed
no metaatnsls.
DISCUSSION
Ono SAP1l111, M.D., Chicago: lliicroscoplcally, one
sees that the dem1a and subjace'llt tissues are .r·eplaccd by D tumor whjch even nt u cosunl glance
appearsmnlignont (fig.14l. It is composed of whorls
and fnscicu li of cells and delicate Rbt•ils. The pattern
vat·lcs bul in genet·al follows an intct·locing and
parallel arrnngement, oriented in d ifferent planes,
usually following gentle curves. The fibrils Me delicate nnd wnvy except. at the margin or the tumor
wh~~ ~~asional bands of conncctlv~ u.~uc are
suggestive of encapsulation. At the periphery interdigitation of cells and fibers can be see11 e>:tend·
ing into the surrounding subcutaneous tissue and
striated muscle with compression, degener:ltion and,
o!l~n . complete isoh\tion of muscle Iibca·s.
The cells a1·e elongated with oval, hig hly plcomor·
phic. hypcl'(;ht·omatic and, at time, mu ltiple nuclei,
the poles o f w hich taper or are slightly rounded. The
thromnLin i.s abundant and varies from n reticulated
appearance \vith focal nodularily to irregular
clumps. There are usually one or two distlncl and
prominent nucleoli, although in some areas as many
as iour are found. Atypical mitoses arc numerous
and extremely bizarre.
At the periphery arc foreign body giant cells with
refractile elongated bodies (sutur e) in their cyto·
p lasm a nd thick compact ban ds of fibrous tissue.
Everybody ngrces tl1at this is a malignant tumor
a11d_, more spccificn.lly, a sarcoma. I -thin k t he diagnosis o f spindle-coli sarcoma is essentially COl'l'ecl,
despit"' tl>c fact that it is only a descriptive term.
It is a noua·ofibi'OSOI'coma butl because of its great et·
ce1lu1arily, may, perhaps. be called a neurogenic
sarcoma.
Acco rding to the history. this 72·yeal··old white
man first developed a lesion on the lower lip fifteen
years ago. The dingnosis js unknown but he was
treated w.1th 1·ndium so one may assume tllat it was
though t to be malignAnt. We may be wrong in this
assump tion. Eight yeat·s later he was treated with
Fig. u . f\ote tbe whorls and f~tsdeull of cella ond Ute tr.ter-
Jaclri.i!
patwm.
At.to Ute t endenC"y towunb paUI&d).nJ: tan be
noted.
irradiation fo1· what was calJed a squamous cell carcinoma of OlO left lower lip. Three years Iuter a
lesion of the le(~ lower lip w"s "gain culled • squa·
rnous cell COl'Clnoma, and it was exdscd. lt recu1·red
at the site or excision and the patit!n t agAi n was
seen three years later. There was no evidence of n
neoplastic growt.h. One year later a slowly growing,
fum, gray mass wos noted in the mldportion of the
lef~ part of the lip and it was removed together with
a suprahyoid dissection. There is no means at the
present time of oscert.aining the nature of the original lesion, but we can speculate that it mlghl have
been at th at time ciLher a oeuroflbromn, u nem·ofibrosm-conu'l 01· t1 sc1unmous cell carcinomn. lf i t
wet·c a ncLu·of~broma this \Vould now t•oprcsent a
be t· o r l'CCUf'I' CI'lCCS. 'fhi.s possibility should bo d isp rogressive increase in t he malignancy, wtth n nurncardcd, o( course, because the lesion originally was
a malign.onllumor. If it were a neurofibrosareoma
CLINICAL PATHOLOGIC CONPERENCE
originally, iL would exemplify Lhe known fact of
repeated locall'ecm·t·ence of t umors of this aort.lt
would also llXplain the (act that the tumor was radloresistanL The tumor bad recurred dc.-pitc irrnmation and, in my opinion, this would be more in
favor of n JWut·ofibi'O$nrcoro~ thnn of a carcinoma..
Finally, H the oJiginaJ lesion were a squamous cell
carcinoma. tJu~-n the ncw"Ofibros.arcoma was cnt.ircly
there is n d istinct tendency towo.rd palisading. The
tumor wa:1 called a clu·cinomn odglnally, but one
can see thnt. it resembles a sa1·corna. In a higher
magnification of the same slide the whorli!lll is apparent and the cellularity. On the basis of the,..,
findings, l call this t umot· a rec u rrent n euroflbro·
s.QJ•comn. Dc£ol'e disc ussing these tumors in g1·eater
detail, we will continue with the n<'xt cases which
are somewhat similar.
FJbros~r~oma; MB1Ij.1nlln~ Tu.mor of f lb:t>19d"··
2. Th;Ulnhaustr . S. J.: Ncurofi bt·omt~toa:lil (von R<!<:klingh awaen) and Oaleoitis Plbrotll. Cystic.n t.ocallsata et Olsem•
t.n.ala ( \•on Ret:klinJ:baustn): Study or Comm<Y.'l Pathogenesis
9f Both DlunHS. DlffermU.tJon BetwC'f:n .. Hypco:rpar:athyroid~
Ism w ith Getlfl'allud Oec'ttleificou!on and Ffbrocystle Ch.-mA:es
or S keleton ond OstcoiUa: Fibrosa CysUc:• Dlssemin:ua.," MeG.
1. Stout,. A. P.;
b l :u:~Loi. Canc..-r 1:30-63,
ill),; 105- H!t 11144.
~ tac-.tllNG\Ilt;: lJ'bO'n\€'LlOM ~
t2.. ) nJmature
Neurogen ic Sarcotna
Hisrory.-(Presented by 'Mark C. Wheelock,
M.D., Passavant Memol'ial Hospital, Chicngo). A
7-duy-old infant h ad a large, red, b leeding, ulcerated ar<'a on the back of the left leg, <>Xtending from
the popliteal space lo the ankle. Ampu tation was
done.
FJg. 15. Note the numbftr of spindlt·Jhtlped cell• with only
ver-y slight ttnCJeucy tOwfm.Js pnlisMllng,
secondary a nd unrelated to the first tumor.
Ever since von Recldinghauscn first described the
cutaneous l~ion.s of neurofibromatosis. investiga tors have uligne-d themselves on one or the other
s ide with regard to the histogenesis of the cells. One
theory supported by Masson and a few others maintairu; that the tumor. arise invariably from the cells
of the shcuth of Sch wann. Th<> opposing school, upheld by MuJio •·y, P enfield., Stout, and othe•·s, believes that they arise {rom the supporting connective Ussue o£ nerves; namely, the perineurium and
the endoncu.rium. A s. n. result, thls Jatler group con ·
slclers all thol:ie tumors librosarcomus a nd n ot neuro..
fi brosarcomas. I might mention th.. t in 1948 Stout 1
published an e xt<>nsive study of 6brosarcomus and
descriOOd precisely what I consider neurofibrosar·
coma. He stated that the rare rnuligna nt Schwan..
noma.s wcl'e confused w ith the libJ·olif\l"COIYU:t:; }>e..
cause the ronner wei'C! capabJe or clabol·ating retieu·
lin. He continues that many malignant fibroblastic
tumors may involve nerves seel)ndarily by lnfi!traLion, an d Lhus confuse the picture. Masson, on the
otl>cr hand, stated thol re<:ognizable Scbwann cells
and the typical polisacling of tumor cells do not
necessarily have to be present in every neurofibroma or neul'ofibl·osaYc:oma. As you all k now, Thannhauser~ who has also done ~x tensi ve wo1·k on neuromatous lwnot·s of Lhis typ~, maintained that
"whorls of spindle cells if present in the fibrous
tissue are indicative o£ its neurofibromatous origin."
be-cause nL one time tht! core was occup ied by these
c~ls which then inilialed the secondary fibrou s
proc<>ss. In other words, he believes that whorls of
tumor cells are almost pathognomonic of the neuro~
genic origin of this tumor; that the connective tissue
(cwmation may b e a secondary phenomenon.
In one area one can see that the tumor is ar·
ranged in the form of parallel fibers. In other areas
D(SCUSSSION
Ouo SAPmn1 M.D., Chicago: The section (6gs.
15 and 16) contains three separate segments: the
tumor m0$8, striated muscle infiltrated by tumor
• (l.nd a portion of skin. T he tum<n· is corn posed of
mnny lm·ge spindle nnd polyhedral c-ells Ol'l'l:mged
in a syncytJUm. A van Gieson stain l'cvcals a
paucity of fibrous tissue represented by fin<' delicate fibrils between the e<'Us. The nuclei are oval
or round. The chromnUn is reticulated with char·
Fi£ tG.. 'n\0 nuclei al)P6&r i1_ighUy more v~kul&r. but aOO
.- tendEncy towards ple.xilonn arram:enwnt can 1M notnt.
actcristie beading at th<> interstices. At timco, depending upon the rotalion of the nucleus, one to two
well defined nucleoli at·e identified. D espite the
uniformity of the cells, slight variation is apparent
on dose inspection. Atypical mitoUc figu1·es are not
ra1·e. Here und tl1ere small cystic spaces lined by
tumol" cells nre seen. The gretltOl' portion of the
tumor .has been replaced by a hll'gc infarct at the
CLJNICAL PA-THOLOGIC CONFERENCE
periphery oi which there is considerable hemorrhage.
Infiltrating between bund les of isolated s tl"iated
muscle are tumor cells. The media and adventitia
of an artery are likewise inAJU·ated and in the lu- .
men are tumor cells enmeshod in clumps of fibrin.
A somewhat different lesion is found in the subcutaneous tissue of the-skin. It i.s composed of paral·
lei fibers and cells intertwined lo form a fasciculated
pattern. The cells •rc elongvtod and resemble those
sN'n in the iumoa·. The nuclei o•·e row1ded or eJongalcd with tapering ends.
Dccalcified portion of bone vlso disclosed the
presence of tumor.
..
I am not certain about the natw·e of lhis tumor.
lL Is malignant and it. is invasive. It was •·ernoved
ls·om an infant and is apparcnUy a congonltal malignant tumor. ln my e-J\.l)erience, there is nothing
mo<e difficult than classifying a congenital maligruant tumor. [t mig.bt be almost anything .nnd, in
porUcuJar, an angiosarcoma or a neurogenic tumor.
As a matter of facl. l calle-d it on immature ncuro ..
genic sareoma nrisi.ng in soft tissue.
IL is composed o{ immature cells oi mesoblastic.
origin. Differential stains were inconclusive. There
were no cellular processes and no distinct struma.
Although I hove no definite basis for calling this
tumor a neut·ogenic sarcoma, I do see a few Hclds in
which the1·e ls a tendency t.owal'd formntion of
whorls. a palisading of nuclei and areas of o. plex iform arrang"nnent of fibers.
The t~rm neurogenic sarcoma was first introduoed by Ewing' who believed that th<>sc tumors
ull arose f•·om tJJc cells of <th~ she~th o f Schwunn.
Stewart and Copcland0 agreed with him and slatod
Ibn~ in their opinion, the bulk of tumors called
fibrosarcomas '"''CI'C actually neurogenic sarcomas.
On the other hnnd, Stout> ;,. the foremost opponent
of this concept. He deplores th~ use of a ter·m which
hus been npplicd, indiscrimiMtely, to any spindlecell tumo•-. He expressed J-eflret that such an astute
morphologist ns Shields Warren should siate thal
neurogenic sarcoma is a recoi!Jllzable enUty. Stout
subdivides the malignant tumors oE the peripheral
Ml'ves into two main groups according to histo..
~euesis: (~) l hoso of mcsoblostic origin and (2)
~Jose of nelll·ocpithelial origin. He believes that
most of the-se tumors are fibrosarcomas and that
only a few, with a slightly dlffc1-ent morphology,
should be called malignant neurofibromas. The fibl·osru·com"s1 he .says, arc charncte1;zed by persislt'nt growth, mnrked ~ndeJ\Cy toward l'ecunence
uud high nldiot'C!Sist.ance, Sb·angely enough, Ewing
IUld others describe id~ntical tumors and mnke identi<:al remarks as far as radiosensitivity is con<:e"rned.
but call such tumors of neurogenic origin.
The literature is confusing because such tumors
htwe been cnlt.'<l spindle-cell SliJ·coma•, flbrosru·c:omas1 small 1·ound cell sa1·comBs, and othet terms.
Microscopically, there is greut. variation. Some ru·e
extremely ceUular while others are mostly fibrous.
Ewin.r subdivides them into tlu·ee types: (1) sclerosing neut·ogcnlc so.como, (2) spindle coil ncuro·
sarcoma and (3) ceUular anaplastic neurosarcoma.
The tumor in this tliSe falls into the third group of
Ewing's classification. Neverthelcs•, I lind il difficult
to gJv c this tumo1· u name.
Lours A. SCHmro&R, M.D., Ft. Wayne: I should
Ukc to mention thoL fat stains were negative.
DR. SAPIITR: I would call this tumor an immature
sai'COtnn, congenital, and believe thnt it may be of
Fl.:. 17. Subcutancoua neurotlbrom.a. Nolco 01~ m:'lrked plt:XI-
tot·m ru·rongement.
ncuJ•ogcnic origin. The bone and bone man-ow nlso
we1~ invaded.
At thb point I would like to rcvic•v our attitude
toward sueh tumors. The genesis is rather perplexing nnd difficult to comprehend. A neurofibroma is
a tumor which is noL enc.apsuln\Ccl. Although It Is
mOl'l>hologically benign, it ls slow growing and h\vasive. When it OCCUl'S in the subcutaneous tissues.
it often contains in its midst a hair •haft. hair Ioiii·
cle o:r a sweat gland. The bulk of the tumor consist.~ of coarse, interlacing fibel's with a few nuclei. I offer this AS ono of the differential poinls botween a new·ofibroma and a fib1·omu. In addiUon, n
neurofibroma recur·s but a fibroma does not.
A recurrent neurofibroma ha.s the same charac·
teristlcs as a neurofibroma with the exception oi
greater cellularity. Th<> cell~are splndle-sbaped and
he~·o and tltere one socs c1 tendency toward palisncl·
ing. Such a tumor should be deslgnotod as either •
neurofibroma, a recurrent neu1·ofibroma or, prJncipaUy beeause of its invasiveness, a neurofibrosarcoma. The tenn sarcoma is used here to imply
lhat the tumor recurs locally but docs not produce
meta~tascs. It should be s tressed ugain that the neu·
rofibroma already ls invash re nnd not encapsulated. Therefore, thougb morphologically benign, it
possesses one of the characteristic features or malignancy.
As the cellulal'it.y o£ the recu1T~nt neurofibroma
or naurofibrosarcomn increases) we us ually call it
a neu1·ogenic sru·comu. In our expcwicnce the cellu·
larity is 1-elated to the invasiveness and ability to
meta.at..a.size. 1n other words, we arc:t: diflerentiating
between the neurofibrosnrcoma nnd the neurogenic
sarcoma. In the former, stroma proclominatcd '\\~hi le,
CLINICAL PATHOLOOIC CONFERENCE
in the )a l ter, stroma is absenL All these tumors are
radio1•esist.unt. They a re different from the Schwan·
nomas o1· n~rorilemmomas.
In the next series of slidos, I shall demon.~trale the
gradual transition of a neurofibroma to o neurogenic sarcoma. This slide demonstrates the prescnc:c
of a sweat gland in the midst of a neurofibroma
(fig. 17). In the next slide one sees a recurrence of
the preceding neurofibroma (fig. 18). There is much
t'i_... 18.
R~
of
$3l'l'le
tumor.
stroma. paliS<lding of the n uclei and a plexiform
nrrnngcmenl of lhe fibers. The nex t slide is from
Lhc second recurrence one vear later. The t.rnnsfot··
matlon Is quite apparen t. Thet·e are atypical spindle
c~Jls with many t..\.unat· giant cells' but no fibers. This
is n neu I'Ogcnic titU'coma.
On. HAJ..L-~ ChnmbCJ'Sburg, Pa.: Dr. Snphh-. whut.
is the relationship
() f
scle1·o sing hemangiomas to
ncu•·oAbromas?
OR. SAPHJR: In my opinion a large p roportion of
sclerosing angiomas are not tJ:ue angiomas hut rath·
cr mor~ or less r ichly vascularized ncurofibrosar·
comas. or perhaps fibrosarcomas. I am not convinced
that the blood vessels ar" the chief constitutcnts or
the tumor.
L£0 Lowotm, M.D .• Tulsa: When would you caU
n tumor a fibroblastic tumor ')1thout reservation?
Dn. SAI1KIR; I consider the 'following criteria in·
dicntivn of n fibroblastic tumor: (1) the prc3cncc of
fibers not in n plexiform arrangemen~ (2) spindlcshupcd nuclei with point\xl ends, (3) no invnslon
und absence of skin appendages within the Lumo1·
• nd (4) suggestive encapsulation.
On. Low bEER! When would you call it a l\b rostu·-
como?
•
Dn. S~\PTTm ; I would calla tum.or a fib,··oso\·comu if
by the v(m Gieson sta
, . · e fibers stained red und
there was no particul
·r rangemcnt of the tibc1'S
and 11uclei and the tu
is not encapsulated but is
invaslve.
Dn. LowasER: Row would you dilf~rent.iate be·
tween a leiomyosarcoma and a neurogenic sarcoma
nnd a neuro6bl'oSal'fOm8:?
OM. SAPHIR: The dlfiereotiation is not so difficult.
The leiomyosarcoma on one hand is round more
commonly in th" uterus o r in the wnll of the in·
test.ines than in the subcutaneous t.issut'S. By a dil·
ferent.ial stain by van Gieson the musdo Ob01·s are
stained yellow. The nudei are sausnge-shoped wllh
round edges. Tumor giant cells are found more oftea
in muscle tumors than in neurogenic tumors.
H>:lfRY PtNKEI!70", MD, St. Louis: I wus interested in a rather remote and theoretical J>OO$ibility,
particularly because o! the> presence o( two diag·
noses of squamous cell c.arc.lnoma and a spindle-c-c.U malignant tumor. S~ve-ral yean; ago, Taylor
t.J__·an!-:planted a mouse carcinoma, grO\Vn In u fertile
egg~ into the mouse and obh1inC!d i"' fib1·osnrcoml•. L
wt~s inclined to discount this u nti l J hnd the same
expcl"ience myself. l bad always bolievQd tlmt nn
opitheliHI cell could not possibly become a connec·
live tis:;ue ceiL al though we do Jmow lhn~ this phc·
nomenon occurs e.xpcl'imentt1Hy. It is u nknown
whetbe1· a malignant change occul'fi in the stroma
with overgrowth of the epithelium 0 1' whether some
otl1er phenomenon occurs. I would hesitate to say
iliut. this tumor maintained the same identity
t.lu-oughoul its course. On tl1e otl>cr hand, I do
think there is a remote pOSSibility thot the original
diagnosis of spindlErcell carcinoma w:ts corrccl
T1u~re may have been an aJteration in lh<!' character
of the cells with the production of spindle cells.
OR. SAi'HIR: Your observations propose tantali>ing speculations. As you kn ow, splndlc cell carcinomas have been described in the skin and in t he urinru-y bladder where transitional coils resemble spind le cells. These t"mors have also been called spincUe
cell sal-comas.
Many years ago Ehrlich trnnsplnnt.cd JllOtasc car·
c.inotn(l:; at:.d Iound a sudden transformutlon ln.to
saTcomns. In addition, the literature nlso contains
many examples of carcJnosarcomus which, in my
opinion, if they exist, a1·e extremely 1·arc. I run cer·
41
Utin that you ba:ve seen the terms lilt e. C011ision tu·
mOT'S.'' "combination tumors." :md '(composition t.u·
mors." In the ucOUi.sion tumors'' n cm"Cinoma grows
into a sarcoma. 1n a "combinnt.ion tumo1·" the stroDU1 of a carcinoma undergoes what is called malignanllransfonnaUon. Finally, in n ucompoesition tu·
mot-'' thQ cell of origin is mulUpo~nt nnd a carcinoma and sarcoma develop in lhe same nrea. E.x·
perimentaUy, sarcomQ and carcinoma may be produced by the> same cardnogenic ugcn l. Often the
sarcomutous lesions look like neurogenic sarcomM.
I have seen such e,.xamplcs. In this particular case.
here, howev12r, Jt seerns unlikely thnt there were
two t umors.
R ICHAno E. JOHNSON, M.D., Columbin: [ would
like to :;H)' tha.t1 first Of all, theT'O l3 n(J histologiC
proof nvall~ble that this man originally had an
epidet-moid carcinoma of the lip. IL wus a clinical
diagnosis made Jn 1930, Cor which he l'eceived ir·
rndiatlon therapy. Could it be poMible that in preference to the possibility of transition !rom squarnous cell carcinoma to fibrosal"Coma, irradiation Jed
to lhe late development of a fibnosarcoma in the
irradiation wound?
D K. SAPKIR: I do not know.
1. Ewing, J.: NoopiMtiC DIIOMcs. PhUttdt:lphlo. W. B. Saun·
ders t.: Co, 19,.0.
2. Sh:wart. F. w ., tu)d COI)4tlnnd. M. M.: NeurogeniC! S1\r·
tCJma. Am. J, C&l.cer ~~ : l235-J320. 1931.
:a. Stout, A. P.: Fibrourcom.a: Malignant Tunxn- ot l"tbro·
blast&. Cam'N' .t :30-63., 1948.
1:!1, Th ymoma
Historu. -(Presented by J:'ranz Leicller, M.D..
City Hospital, St. Louis). On March 28. 1949, this
60 year old white man entered the hospital for treat·
ment of Incipient gangrenous change in the left
heel. The patient bad hnd gangrene of the r ight
foot with n rnidthigh }lmputation pcl'foJmed on
December 30, 1948. On pbysicnl examination the
only :pertinent fmding,s were a healed right mid·
thigh stump and a purulent ulcel" involving the pos·
tcl'ior portion of the left heel. Laboratory find ings
showed a white blood count of 11.600, t·ed blood
count of 3.7, nonprotein n ill"Ogen 24 mg. per cent~
sugar 73 mg. per cent, and negative Kahn test and
urine. The ulcer on the loot did not respond to
therapy. The patient had a cerebral occident on
Junc 1'7, 1949. witlt resulting right hemiparesis. H~
!ailed to rally following this episode and expil·~d
on June 29, 1949. Terminnl nonprotein nitrogen wns
80.
At autopsy, in the ant«:!rior-superior mediastinum
in the region of the thymus gland thct•e was o firm
mass measuring 7 by 4 by 2 em. and weighing 40
grams. It wn.s composed of ·w hitish yellow~ modcr·
ately firm~ homogeneous tissue partitioned into
numerous lobules varying from 0.5 to 1 em. in
p;g. 19. MOlt of ' be 11.m\or coru)Sl$ or thls tYJ)(' or c:tll
( Utym(I()1H') ,
diameter. The entire mnss \\.'as Stti'I'Ounded by a
fibl"ous C'tlpsulc.
DISCUSSION . ,
OtTo SAPU.m, Ai.D., Chicag~.e .section shows
a striking resemblance of the cellular pattern to
Utat of a S!lrcoma (fig. 19). The tumor is composed
of whorls, sL1·ands and interlacing bands of ovul,
J>Olygonal or elongated cells separated by a small
amount o£ stroma, and further subdivided into
cellnlar masses by large o.riounts of thick fibrous
and: at limes, hyalinizod cotlncctive tissue. The
variation of the sizo o f the cells seems to bo 1•elt1ted
to th e degree of compactness of the cells. The cytoplasm Is •canty a nd fainty acidophilic. The n uclei
contain o fine rcliculoted cbromaUn. No milost'S are
seen. -H ere and thel'·c one is able lo disccm cysts
lined by poorly doAned cells resembling t hose of
th e tumor (fig. 20) . The cysts contain altomogcne·
ous pink staining materiaJ. Iiowcveto, a t one margin
of the section the cysts contain larg" vacuolated
Fi.g. 20. Nota early
~yst
!ormation.
cells w ith pyknotic nucleL Relatively small num·
bers Of lymphocytes (or perhap• these are the SO·
called ''thymic Jymphocytes") Rl'C scattea·ed nmong
the tu.mw- cells. Rnrc a bortive Hassall's corpuscles
can be seen in the tumor. However, in the surrounding [at one can see well defined Hassell's corpuscles (fig. 21) .
I think Umt in Otis case the Mfcst diagnosis is a
thymomtt1 judging lrorn its p osition in the ant,el'lor
and su pet·ior modiuUnum, its encapsulation and its
histolocic pictm-e. The latt<>r, in general, Is that
oC a lymphosarcoma. It would be interesting to know
wlH~thol' or not this putient ev~r hud :;ymptoms of
myasthe nJa g ravis. This is th~ type of tumot• wh ich
commonly is associated with tlte clinical syndrome
of myasthenia gravis.
Tumors of the thymus, in general, have •·esisted
classifict~ tlon -fo1
· muny yen rs. 'l'hls has been due
to lhe lt~ck of a.gl·ccmen t as to the histogenesis of
Ole tells. Two main views have b<>cn proposed. On
one hnnd, the small thymic cells nrc believed to be
histogenetically and rnorphologicolly related to the
blood lymp hocytes itnd, therefore, of mesenchymal
origin; o~t} other view maintains that t he thy mic
cells were deri\led from the entod<tl'mal r eticulum.
Ewing' divides thymic tumors into three types: (1)
lymphosoz-coma or thymoma, composed of diffuse,
t•ound, po lyhedral ~ nd gian t cells, (2) carcinoma,
arising lt·om the •·eticulum cells nnd (3) spind le·cell
sarcoma or myxosm'COma. The latter is rowe and
probably oris(>s from the stromo. He felt that the
tenn thymoma should be used In the same sense
as lymphoma.
Symtncrs:! presented five types: (1) peeitholloma,
whicll arises around t.hc blood vessels in the thymus,
(2) epithelioma, (3) lymphosarcoma. (4) spindlecell snrcoma, and (5) Hodgkin's granuloma. The
CLI NI CAIJ PATHOLOGIC CONFERENCE
most recent classification was given by LowenM
haupt3 who believed that all the thymic tumors arc
of epithelial origin. Her classifie.•tion is as follows:
(1) carcinoma of primitive epithelial reticulum, (2)
carcinoma of variegated c~ll pattern (carcinoma of
early HassaU's corpuscles, witl1: or witl1out aborliv~
linssnll's corpuscles~ (3) ctli'Cinoma of granuloma~
tous p f•Uern (cm·ciuoma of lnte Hassall's corpuscles;
. .· .
. '
-,.-
..
, .. '·
),
.... _.,.
Ylg. !J. Note Hauall'1 c0f11'HCI. 4t the l)('ripbery
ot the
'umor.
thymic Hodgkin's disease). (4) carcinoma of thymic
round c~lls, lymphoepilheliom•, (5) encapsulated
1hyll'\Oll'l<\ and (6) ca rcinoma o( adamantin omatou.s
pnttcrn.
I bcli~v~ lhat this e<l Se full$ into the gt•oup of
encapsulated thymomr~s. 1 hnve seen one ex ampl e
which I Lhought to be of the nclnm:mtinomatous pai·
lcl'n in a patient with a_ typlcnl picture of myasthc·
nio gravis. I was so interested in the turrior that I
sent it to the Registry but none agreed with m~.
At that time I considered It a tcratoma which arose
in the region of the thymus with unilateral devel·
opment, this particularly so because I had found
011C instam~e On record of nn ndnmantinoma arising
ht nn ov~u·y. lt was thought t..o bc\a u nilateral devclopm<"nt within a te.1·aLomn~
This case can also ·be call
a lymphosarcoma.
The cells do resemble lyn•pt•o tes a lthough ol'ig·
ln ully they were coJied thymoc es.
In this photomicn,gruph the patlem of the. spin·
die-shaped cells, the so-coiled thymocytes, as well
as Utcir resemblance to lymphocyt.g, is evident
There are small cystic structures similar to those
often found in thymuses of the newborn. There is
a tendency toward the fol'mntion of Rassall's corpuscles.
1, Ewtng, J.; Neo1>hu~Uc DI!!IC:Il!WI". R Tro<~lisc on Tumo ..IJ,
f'hlfade1pbla. W, B. S.umderf Co., 4~h cd., 11HO.
2. Symrners. o .: MalJJtOMt Tumors a nd T umQr .. lllk<:
Crowths of Thymic R(igUm. Anl\, Sur" . 9 5 :SU-572. ! 932.
!1.
Ul~
Lowenh.aup\. &.: Tumor• or the Thymus in Rc!lation to
EplthC'llaJ Anl;age,
Ct~nCt!r
'1 :!1117.. 58:1, Hl-13,
lit , Plasmocy toma
Hi&tOT!/.- ( Presented by F. G. Stephons, M.D..
McMillon Hospital, St. Louis). This 52 year old
white man was referred to nn otolaryngologist for
treatment of sinusitis. During the coursc of physical
exwninaUon a tumor of the epiglottis was noted.
This wos pale red in color and consisted of a mass
on the laryn geal surface, measuting nbout 1 em. in
diameter. There- was no invo)vcmca,t of adjacent
stl·uctures.
DISCUSSION
OTTo S APT-t m, M.D., Chi«>lW This section (figs.
22 nnd 23) shows invasion of the deo·ma and sub<a.t loneous tissue by an extremely cellular tumor.
The cells vary (..-onsiderably in size und shape. Giant
tumor cells containing as many as four nuclei are
numerous. The cells are oval, or polygonal. with
•bundant, intensely basophilic cytoplasm. Adjacent
to the nuclei. occasional pale round tu-e&s are seen.
Tho nuclei are eccentric., 1'0Und or s lightly oval with
u p1·ominent centra l nucleolus. The chromatin is
course cmd dfll·ldy staini ng and clumped tlround the
nudcnl' membn'lne. The cells m·c scpnl'ated by small
umounts of fine connecli ve t issue. There is hetnor·
1·hagc into the tumor.
I called this a plasmocytomn on thc basis o f hav·
ing seen a similar case before. The lesion is char·
aCtCJ'itcd by diffuse infiltrations o£ lal'l:C cells ";th
ccccntric nuclei. Tbe chromotin i• clumped and,
only rarely, does the nucleus actually l''esemble a
cartwheel. ...,T he cytoplasm i$ slightly basophilic.
There arc a n umber of muJtinuclcnted cells. I believe that this is a benign tu.mot·. J have seen only
on.e plasmocytoma occun·ing in t he lons ils. This
l.!.iuse wflS cvcntual1y repol'ted by Ft•m, k 1
Ewen considered these t u!'nOJ'S ~1s usually be-nign. Accumulations of plmlnl{l cells, soen in in..
stance~ of c hronic in flammation, are usufl lly- kno\Vr'l
by Boris' tenn ugranuloma plusmu ecUuJat·e.'' Helwig.: in an extensive general study on cxtramedul·
lnry plavna cell lumors, ""Po•·ted 127 published
cases of this type. Of these slxly·thrcc originated
in the upper respiratory tract. Hellwig concluded
thn\ 11 the plasma cell is considered n differentiated
lymphocyte, then the extramc<.lullury plasma cell
hunor· falls in to the lymphoma gr ou p. He believed
t hnL l.hc extramedu llary plasnla cell tumor, despite
tl•c \ypica I cell structure, m ight o·an gc from a non·
molignt~nt to a highly maUgntlnL !(t'Owth. He fowtd
nincsuc:h t umors of the airpasst&ges with metastases
lo bones. He _remarked that some lnvestig~tors re-j~nrd the extramedullary plasma cell tumors as be·
ing fundamentally the s..me as multiple myeloma.
He disagreed because it appeared t o him that plas·
mo ccl1 tumors, observed for many years, always
rcmuined benign and localized, panlcular ly those
occurHng in the mucous memb1·ance. Recently,
Stout and Kinney' studied prlm!lry plasma cell til·
mOL'S of the u pper respir atory t ract nnd oraJ cavity.
In t.hcil· e xtensi ve review they found Jour instances
in which the laryn x was involved. From their study
they concluded that a plusmn cell tumor can ond
does display infiltrative growth. Such tumors dcfin·
ilcly occur in the nasal and oral mucosa. The- in·
CUNICAL PATHOLOGIC CONFERENC£
volvement o{ bone marrow mny be e.x"'J)lain ed either
On the basis O( LI'UC metas tos is, if they are rnalig·
nant~ or as new lesions similar t.o tile pri ma,ry tumor
since they a re usually f o und wh e re potential p las·
mocytogenlc cells exist. They conclud ed that the
plasma cell proliferation of the oral and nalUII cavity
ore plasma celL.neoplasms with either solitary or,
rarely, multiple manifes tations; lh~y c.a n metastasize to xegional lymph nbd caj Oley arc sometimes
as..<oclated with solitary or m ult.l!li<> involvement of
fi.~,t. 22. Nol.: tho 5\l bmvco:~l\ tc\'di'Ciy infilt ra lcd by cells
~SoeJnbUng pJasnH• ~us. Some of theve 11re multlnuclculcd.
bones. It is interesting that of the four cnses o£
laryngeal tumors, th~e was recurrence twice in
one insgmcc-, Howevet·, follo wlng x-ray o·cotment,
the patit'!nt wns f:re e fr om symptom s fo r fOUL'leen
11nd one Jlalf ycru-s. '!'his would in dlcate tllaL suc h
tumors do recur and that irr adint.lontherapy Is indlcated in each reeurrence.
This is a rare lwnor. I beUove that these tumors
in the oral cavity ore not related to multiple myc·
lc>ma o£ bones. They are locol manifestations o{ a
peculiar type of lesion.
Jn tfsese slides there is invasion of the derma
and the subcutaneous tissue by on e.'<lremely cellu·
lar tumor. There are occasional giant tumor cells
with as niany as Cow· n uclei. 'l'he c::ells aro ovnl or
polygonal. At Limes, the eccon llolcity or th" n uclei
i$ distinct, lhe chroma~
· is cotm; e an d clumped
around the n uclear mem
nc. The ceHs 01'C scp·
arated by small amounts o
o connective tissue.
LAt1REN V. AcK.ER.MA~1 1\: • ., St. Louis: l have
seen a .fai r n umber of sur;h ~\lmors in the upper air
possages a nd I would sa y LhnL as a gr oup they
plasm o.s this is radiosensitive and radiocun'lble if
i t is loc»lized . If there is no oceu ll focus, the•·c is n
chnnce of c u1·~ 01· nr rest. w·e h ave ulso had tho ex..
peric n ce of seeing n patient Jn whom the p rima ry
manilc•lation o f a diffuse p lasma cell myeloma was
within the oral cavity, As I see these diJierent cases,
p lasrrw cell lumol'$ arising in soft tissues, perhaps
sing le l oci in bono, o1· even plasma cell le ukemia
(usuully a n acuto process) they appear to >·cpr c·
sent n usances o f Ulc sam.c procesg proceedins nt
variable speeds. I am more dlsposed to look at thi•
as all the =e problem rather than as multiple
problems.
M. D . WnEELOCI<, M.D., ChiCafiO. How u·equcntly
do you see plasma cells in the pe ripheral blood, and
how olt.en do you sco plasma ccl13 in the per iphc>·ul
blood in dlffu.-;e pltl$11Ja cell myeloma?
DR. SAPHlR: I do not know. I would say rarely In
my limited experience wi th the blood picture.
D~. ACKP.RMAN : One does see Lr uc cases of piO.S·
1'1\Cl cell Jeuker'l:'lia; ther e are nbout thirty·five or
thes~ in the Hte•·atul"e. In mu lUp l<! myeloma one
rm-.,ly finds plasma cells in the pel'ipheral b lood.
F<>W hematologists search a.<siduously for the plas·
rna cells in the blood stream. In cases or this natUI'e,
! think it would be u nlikely to have t.he cell• in the
p o.-li' h e ral blood 11nd I think it is iln po.-tant, g iven
a pntlc nt of this nH LUl'C, that tl1o case be investi·
gat«J tJ1oroughly to be sure there is no d i.~cminn·
tion. The serum proteins, bone m orrow biopsy and
Bencc.Jones protein should be dono. I! th"'"' find·
ings are negative, the patient mny have a bcttc.r
ch n1wo of h av ing n shtg.le localized lesion.
DR. SAPBIR: Is ll not relatively l'::u·c in cases of
typ icol multip le myelomas to find extramedullary
lesions?
grow mor e slowly than the usun l m ulti_p lc 1nyeloma
(Stout). It is not a t all uncommon for tl>cse pa·
!Ients to eventually de velop the typical clinical pic·
tu.rc of a multiple myeloma. l n my limited cxperi:
cnce. lhosc cases in which the lumor was in lhc
upper ail' pas~ges and in which there w ore g iclnt
cells and vaJ·it~t.ions in s it-e a nd shape h ave p ro v\.~
to be uniformly more malignant than the group in
which the plasma cells are easily reeognized ond
quite uniform. In this la tter group it is difficult to
predict the prognosis. Next, I think that il Is important fo r ~vet·yone to realize tha t su ch u. neo-
Dn. A CKERMAN": Yes: i t is ~·cl ntlvcly r a re, but
there are. cases in the Hleratur~ in which there are
lesions of viscera.
Ro"DtRT JlofooRE, M.D., St. Louis: I think one sh ould
not J>ny too much nlt.ention to termlna1 invasion of
CLJN/CAL PATHOLOGIC CONFERENCE
blood h\ ''ru·ious ro J•ms of rnnlignant tumors <)( the
hemaU>poietic lissucs. I do not belie,•o that this observation alters the fundamental nature of the dis·
ease. We have one example in the ftlcs of our Department of _OLolm·yngology of a plasmu cell tumor
of the tonsil will> n lymph node in the necl< which
was pure plasma <:<!Us. I do not know what has happened to that pntiont.
DR. A<:KERMAN: r also saw that patient. At the last
follow-up there was widespr•ead involveme.n t of aU
the flat bones of the skull.
DR. MooRE: That was about four yeors following
lhe pl'hn u•y diagnosis. wns It not.? I was jt1st going
to say that it is my impre..~lon from HellWig's pnper
that a consideTfblc percenlnge of these people with
plasma cell tumors of the rcspiratory passagcs will
eventunlly show p~asma ccl_l n'lyeloma of bono. This
patient aubsequent ly died of disseminated myclomtt .
At autopsy there was extensive involvement. of the
skeleton.
l. Frimk. I : PlatimOCytoma of Ton.sU, Anu. Otol.. RhlnoL
:;1. :22-28. 19(2.
2. Hdlwtg. C. A.: Extraordin;.ry PlAsm• Cell Tumor• as
Obsen.'(!d In Var!Ow: Loc:,oa!Ion:s. Ardl. Pitlh, 30;9$.111. 1M3.
3". St6Ut. A. P-\ a.nd Ken.trey, F. R. : Prlmnry Pl.:ums-«ll TU 1.; LarynJ .
mors ot O'Je Upfle:r A ir P<JMages t~n4 Oral Cnvhy, Canc;er :::261 •
218. 1940.
1\1'(/,,l\1)111~ , "f'1IC u"\ie1t>IW!N1.'1)
15.
Hn6himoto'~ Diselli!C
Hist01'!/.- (Prcsented by Lauren V. Ackerman,
M .D ., Barnes Hospital, St. Lou is) . The patie nt was
n thin, pnle, alcl'l white woman, aged 33, w ho thre-e
years ago noticed that the thyroid gland was hu-ge.
She consulted a pbysicinn who thought she had
hypo thyroidism and gave her tableta. She hnd noticed a d1·awing sensation In the thJ·ou t and over a
period of sLx years she had lost weight from 13.7
to 1J I pounds. On admission, the thyroid wns fu-m
and enlul'ged; i t mensw·e<:l appro ximately 1 by 4
em. Then'! were manY smnU nodules and one hol'd
2 em. nodule in the right lobe. Basal metabolic rate
was piWJ 3. Peripheral blood nnd urine examinolioos
wet·e no•·tnal except for slighl anemiu or 3.8 mi. •·eel
blood count. Se•·um protein f.Lnd sedimentation rotc
and electrocardiogram wea·e all normal. A total
thyroidectomy wos done.
The gland wn< ancap!\Lduted, weighed 38 gr~ms,
and h nd '' p1•omin n t tracheal c urvnture. The external sut·f~ce: wa.s
ely nodula-r and symmetrical.
On section, the th
d was firm, yellow gray and
homogeneous.
DISCOSSJON
•
Orro SAPHIR, M.D., Chicago: The tissue is identified by the presence of" row scattered and atrophic
follicles (6g. 24). The lumen contains scanty
amounts of variable staining coUoid. At times U1e
epithelium is hyperplastic with obliteration of tho
hu:nen nnd absence of colloid. Most prominenl o·r e
the lnrgc lymphoid follicles with lna·ge germinal
cente•·s and the extensive lymphocytic and plu.sma
cell infiltration surrounding and compressing the
o.c ini. Lobulation Is mimicked by the thick b ut delicute and cellula•· connective Ussue . At one morgin
the masses of fibl''OUS tissue appear to have re-
p loced l obules. The blood vessels show none o£ the
changes rescmblin.g o~c endai'Le:ritis seen in so·
called Riedel's strumn. At times pseudo giant celu
fo•mod by a fusion of coUoid and cpilhclinl acinar
cells can ~ seen. However, the history, physical
find1ngs, gross appem·uncc of the thyroid, and the
microscopic picture .,.., all compatable with the
dingnosis of struma lymphomatosa or Hashimoto's
dis(}ase.
[ tl>ink the diJfeo·e•>tial cliagnosis lies between
Reidel's struma, Hashimoto"s disease and carcinomn. The majority believe that this is Hnshimoln's
disor.se. and 1 agree.
In reviewing t11e hist.o•·y of this patient one see.~
that she wru; a 33 year old woman with t.wo ma)or
comp1aints- a goiter for three yeill'S and a drawing
sensation in her throat. TheL
·c wus a possibility of
hypothya·oldlsm. ClinlcaUy, the thy·•·oid was Brm
and enlarged. Multiple small nodules and a solitary
honl nodule In the right lower lobe were felt. There
wn~ a s light anem ia. The lesion was described :1$
being enct•psuJat.ed 1 finely nod L-llar and symJlletrl·
cal. It weighed 38 grams. The cut section was firm.
yellow grey and homogeneous. In the evaluation of
the strumns, n clinicopathologic con-elation is often
nct.'Cled. In occordance with this, there al'e two ad·
dllional fact.s which I would like 1<>- have: ( 1) the
absence or presence or adhesions around the thr·
rold, and (2) why a tollll thyroidectomy in this pur·
llcuhU· instance WR!' done t•otlu~J· than a subtotal
thya-ojdectomy? Does anybody know ?
LAUk!:N V . ACKERMAN, M.D., SL Louis: First, no.
As I recall, there were no udhcsions. Second, 1
asked the some question and I'Cccivecl no answer.
But. because of the hardness of the gland I think
there was some question in tho mind o( the sur·
geon that th is might be a malignant neoplasm. No
h·ozcn section was don<~ (for which I am t.hMlkful ).
I would certainly think that n taU.! thyroidectomy
was not indicated.
Dn. S APAm: Yes. Since Hashimoto first described
lhls entity in 1912 as " lymphoid goiter" and par·
Ucularly 11.'1 contrasted witlt Riedel's fi>'St desc1ip·
lion of what he called the uEisenharte Struma1 ' or
uSLJ•uma Hgnca" in 1896. there has been a battle
about the possible ,·olatlonship of tbe ~wo diseases.
Hashimoto was emphatic U1at Lbey wer~ two sep·
arote and d istinct cntllies. Ho was supported by
Gl'8ham3 who, as you know, has done a large
amount of work on thy •·oid le sions, and by other11.
Ewing stated Lhat strumet h rmphomatoso and Riedel's struma ond Ha.mimoto's di..ase of the thyroid
were the same proce~ and classified them_~ Hbenign granuloma of the thyroid." 0£ cou•·sc, in both
Riedel's st.-uma and Hnshimoto'a disease of U>e thy·
roid there are granulomas, probably due to an extrAvasation of colloid which acts as a foreign body.
Hnshimoto's stl·uma,
o1·
pl'cferably Hashimoto'$
disease, occurs almosL oxdusively in women, is seen
at any age, but chiefly during the third to the fifth
decodes. 1\ may be nttaohed to the trachea, but
tho1·c is no ad11erencc Lo th~ surrounding structures
as is present iu Riedel's struma. Th~ consistency
CLINICAL P.,tTHOhOGIC CONFERENCE
b; li,tm qnd r esilie n t, at Um~s hara, but never as
woo'dy as in Riedel's Stru.me:1.
Micr·oscQ'piCally, the acini ure small and atrophic
with ~ccmfy and poorly staining colloid. There Is
a diffuse lymphocytic in6Jb·ation of the p~u·enchyma
and large., often numerous. lymph lollicles with
ltuge genn inal cet.Je1ts. ThiCk or fme wavy Jibl·ous
llssue sunounds the. acini and in the late stage
lll~re may be a gradual Hhrous replacement of the
job.,les. It is t.h.i.s Hbrous replacement which bus led
to the i:uler ence that a 1·elationshjp exists between
Riedel's sb,uma and Hashimoto's disease. Plasma
cells, monocytes and often pseudo giant cells fU'e
fo.und. Tire p•·esence of endurteritis and blood ves·
sel changes fo und in Riedel's struma are not described in Has,bimoto's- d isease.
In contrast1 Riedel'S st~·umn ocow·s in a younger
age group 1 usually- in the thll·d or fourth decades
<'!lld is seen both in males and fe males. There is no
tendency to myxedemaj the latter occurs only if too
much of the th yroid tissue ho.s been removed $Ul'gi·
cally, The goiter in Riedel's stl·uma i~ $mall, hard
and smootll. Inva.tiablY, there; is fixation of tJu~
thymid to th e sutrounding, structures. Removal fs
so (lifficult that, a.t i.Unos, the J·ecw...e nt laryngeal
nerves,. cartoid a1·lety, jugular vein, esopjlagus or
ony one of th e adjacent st~uctures may be injured.
Microscopical1y, the most p rominent featu re in· Rie·
doCs struma is the large amount of dense hyaline
and Jibrous connective tissue. The acini are compressed .a nd few in number. The a lierioles a nd ·the
ar.teries a:re invariably the seat of a severe endarlerllls, the end stages of which ore identicuJ to t hose
seen in arteriosclerosis.
The etiol'ogy of neither disease is known. Stt·u..
ma lymphomatosa is perha ps t he l'c-sult of a constitutional a nomaly or th" result of metabolic disturbances. There arc some l·efercmces in th(! liter·ature in whicl~ s1:1c.h a d isease ·bas been produced
~xperfmentally by low vitamin carbohydrate, lov.•
vH.aminlat and lo'i.v vi tamin protein diets. At present it is jmpossible to state that the disease p roduced by such deficiency diets is ideniJcal with
Hashimoto's disease. In closing, ·r should like to
say that i t is often. difficult to ma'ke. a d iilenmtial
'
'
d iagnQSis be.tween Riedel's sh·uma a nd Hashimoto'~
disease fi·om one Jield or u·om one·section alone.
DR. -AcKER,tAN: May 1 say that I included this
sliae because I was unable to decide whether it
\vas Hashimoto's d.lsea.o:;e or Riedel1s strurt\a1 a:nd my
£n al diagnosis was uthyz·oiditis." I thought that on
Fig. 2:<1. Note the pre$t:nce of :1trophi<: Iollide$. m:.n)' ln·
nammafory ceUs ond
~iant
ceUs.
the b asis of the clinical history a.n d the g•·Os.< appearance of the specimen 1-Iashimotois dl!;&ase was
favored. In addition, the absence of e:my attachment
and the symmetrical involveroent, according to the
su.rgcons1··w oul d be against carcinoma. The· lack o£
a'dhesi<ms and the diffuse invo1vcmcnt a.r c against
Ried elJs st.ntma. R jedeJ's st.ruma is asymmc bi.cal.
stony hard . with dense adhesions to su:n:ounding
s tructures. The dlffuse involvement and lack of
adhesi<:ms is £or Ha$h.imoto,s disease. However1 the
fibrosis a nd_giant cells a.re against this disease. I.
the1·e.£ore. favored clu·onic thyroiditis~ ofteo a dif·
fuse p-r:oce~ with few adhesions. Microscopically 1
_it m;.~r Produce a variable pictu-re w ith giant cells,
fibrosi,s and increa~ed ~ympboid ti~s1.1e.
1. Andcrwn, W. A. 0 . : PatJlology, SJ. Louis. C. V. Mosby
co..
19118.
2. Sc-b.iJHng, J. A.: su-uma Lymphomatosa. Struma Fibrosa
and Thy roiditis, Surg.• Cynec. & Obst. $1:533-SSD, H145.
3. GritbQm, A.: Mt~llgnnnt Tumors ot Thyroid. Epithelial
Types. Ann. Sure. 8 2 ; 30-44~
1~25.

J - Rosai`s Collection of Surgical Pathology Seminars

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