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S U R G I D A L l' A T !: 0 l. 0 ~ Y ~ ,:: ~! ! N A H

U. s. A R ~ ! ~ 0 S P : T A L, N E U B R U· G K E

U S A R E U R M E D i C A L L A B C R ~ T 0 R Y

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CASE NO,

1 I 2

7

8

ll

l2

13

l4

15

l6

17

l8

SENINliR CASES

C-2bll 7

3249- 54

2~---55

S-2S::.ll

S-J'J;OO

S-.3 ~?.36

S-.31302

"S-31294

S-3JJ42

S-31279

S-25729

S-32237

3228

S-265J.S

3775-54

:>!AGNOO!S T ••

;.y;n,,hl•fa~·r.;e>'Jl?., Reticulum Cell

··~ ,::> l..y:t:··1'o~ar.cC"·n~., !.~j~phocytic T::::·:.~ , Sr.'l;;l: ~ntestir~s

1.1 p >ea:·co~s of Popll t11al Ee;;1cn

t,J •JQO '.ar Sa:-colll'l , Sd't Parts

Cr.:mc'.roma

Fi:;;-o~arcoma Arising in a Neurof~.brr_:r.la

P.y:.l:· ad ':~•oma

11yoepithelioma

Hul ti p1e lclye l ema

hOini Cell Carcinoma, Parotid

Intraductal Carcinoma, Breast

~de~~carcin~ma of Overy

Adqno~arcinoma, Submaxi~1ary

Papi.llary ndenoca Carcinoma, PCJ.::-ct:i.d

f:ur.thle Cell Carcinoma of Thyroid

IntP.rstiti ul Cell Tumor of Tes~is

Tllo!OR ruMINA.R, U. S. Am.IY HOSPITAL, NEUBRUCKE, DR. SEVERANCE

case #l - S- 3ll94: Patient is a 24 year old wb.ite male who has had a mass in the left axilla for approximately 10 months. It has more rapidly enlarged during the last 6 months . The specimen removed consisted of two large masses of fatty tissue within which were markedly enlarged lymph nodes. These appeared more or less discrete and showed a firm grey white cross section. A pigmented mole was removed fran the left chest at the same time . This proved to be a canpound nevus.

case#? - 8 -30774: This 20 year old white male bad noted a right lower quadrant mass f or approximately three weeks with some pain in the same area. The preoperative diagnosis was appendiceal abscess . At surgery a mass was found in the area of cecum which was estimated to measure 10 x 15 em. A biopsy was obtained.

case #3 - S-31587: This patient, a 42 year old male negro, was hospital­ized for severe upper abdanina.l pain and CI'BZ!!PS vhich bad been present for approximately 12 hours. Past history revealed previous episodes of a similar type pain . On examination a small stab wound was noted in the left upper quadrant. After further investigation it was determined that he had been stabbed ll days preViously with a knife measuring 2~ x 5/16 inches. At surgery a section of indurated gangreneous small bowel vhich had a complete circumferential rupture was resected. The patient vas treated for peritonitis. A secondary clos'\lre of the jejunostany was made several weeks later.

case #4 - C-26117 : This material is the second excision of a tumor from the belly of the triceps muscle in a 19 year old male. It had originally been removed one year preViously and had reappeared four months prior to the present surgery. The operative note states that the muscle vas easily stripped avay. The tumor measured 4. 7 em. in maximum diameter.

case #5 - 3249-54: This patient, a 54 year old white female, complained of a swelling in the region of the right knee for one year . After sane delay and three changes of doctors 1 she vas admitted for biopsy. The right leg was markedly swollen below the knee and a bard indurated mass vas noted involving the entire popliteal area. X-ray examination revealed soft tissue swelling around the knee joint and fluid in the Joint caVity but no bony changes . After a biopsy the l eg vas amputated. The ampute.­tion specimen revealed a 14 x ll.5 x 8 em. tumor mass in the popliteal area. On section t he tumor vas hemorrhagic and necrotic with yellowish triable areas . The s l ide included f or study is from the amputation specimen.

case #6 - 21-55 : This 20 year old female was 7 months pregnant. At that time three tumors from the left breast and one fran the right breast were excised. All four nodules were of the same size and gross appearance being relatively soft, sanewhat mealy and measuring 2 .5 x 1.5 em . Follov­ing removal, additional. history indicated that a questionable small tumor mass bad been noted in the left leg near the greater trochanter for a number of years .

Case ftr - S-26lll: This lesion in a 6 year old female >'8.s incidentally found on x-ray examination during an acute .l'ebr1le episode, probably a URI. Physical examination revealed only an irregularity at the 5th right costo­chondral Junction. The x- ray showed "lysis" of adjacent rib.

Case #8 - 8 -3038o : This 2 year old male was seen because the mot her had noted a protruding tongue . He was slow in talking because of the enlarged tongue. No other physical findings were noted. Grossly the tumor occu­pied the rigbt side of the tongue near the base and shelled out easily. It measured 6 x 3 x 2 em. Several pieces of .finn pale tissue were removed. The largest appeared elongated and lobulated vith a smooth shiny outer surface. On cut section an inde1'in1te nodularity was noted.

Case #9 - S-32236: This 35 year old female patient presented a small sub­cutaneous tumor on the dorsal surface of the 4th toe. The tumor 1re.s movable and easily enucl eated. The gross specimen measured 0 .9 em. in diameter and on cut section appeared greyish with yellow spots .

Case #10 - C-31302 : This 52 year old mal e had not ed a nodular tumor mass in the rigbt buttock -for 2 years. There is a statement that a previous excision bad been performed With the diagnosis of f ibroma. The present excised specimen, a nodule 1.5 em. in greatest diameter , was removed .from the subcutis . On cut section the nodule appeared semi-translucent and somewhat lipomatous .

Case #ll - S-31294 : This 36 year old male had a one year history of aching pain in the upper anterior chest and lett shoulder . There vas a 6 months history of increasing fatigabilit y With a 15 pound weight loss. A mass was found involving t he left sterno- clavicular joint area . X- ray revealed destruction of bone in the upper sternum and left clavicl e . Incisionsl biopsy was performed .

Case #12 - S-31342 : This 46 year old female had noticed a small mass beneath the right ear for 5 months. This mass was slightly movabl e and not attached to skin. Inci sional biopsy revealed the mass t o lie 1.5 em. deep to the skin below the angle of the mandible .

Case #13 - 8 -31279 : This 53 yr . old female had noted a mass in the left breast for 3 months . No aXillary nodes were palpable . The specimen removed consisted of a mass measuring 6 x 4. 5 x 2.5 em . which on cut section showed an increased consistency with many minute transparent cysts. Centrally the normal breast pattern was replaced by more yellowish-grey tissue.

Case #14 - S-25729 : Except for easy fatiguability and listlessness this 37 year old female had no particular symptoms . She had noted a gradually enlarging mass in the abdomen for 2 months . The uterus, right tube, and right ovary were removed. The ovary measured 13 x 9 x 8 em. On cut section the ovary showed a well encapsulated tumor of variegated appearance and consistency. Solid yellowish or pale white firm areas were intermingled with soft or cystic areas which were gelatinous and mushy. The uterus contained a l eiornyana measuring 6 em. in diameter.

Case #15 - S-32237 : This patient, a 35 year old rema1e, had noted a swelling in the region of the lett submaXillary gland for 6 montbs . On palpation a hard, non-tender tumor approximately 3 em . in d iameter was noted. The submaxillary gland containing the tumor was excised without block dissec­tion. The gross specimen revealed a submaxillary gland containing a solid tumor centrally but presenting also on the surface of the excised gland.

Case #16 - 3228: This 41 year old negro f emale fi.rst noted a mass posterior to the angle of the left mandible 6 months prior to the current hospitalization. She was 8 months pregnant when the mass was first noted. During the 6 Jllonths period the mass increased in size to that of an average San Antonio pecan.

Case #17 - S-26548: The patient, a 36 year old mal.e, was found to have a nodule in the right lobe of the thyroid on annual physical examinati on. The right lobe of the thyroid was removed. The pathologic specimen measuring 5 x 2.7 x 1.7 em. exhibited a dark pink parenchyma. The lower pole contained a circumscribed ovaoid nodule 1.7 em. in diameter with an attached smaller 0.6 em. nodule . Sections of both nodules showed glistening, semi-translucent firm amber- colored surfaces .

Case #18 - 3775-54: This 44 year old truck driver was seen for an acute urinary retention. Examination revealed an enlarged hard right testis. Cystoscopy reveale~a vesicle neck contracture. The testis was removed at the same time that a transurethral resection of the bladder neck was performed. The testis measured 8 .5 x 7 x 6 em. CUt section revealed most of the parenchyma replaced by a rubbery f irm whitish tissue which contained a central brown area measuring 4 em. in diameter.

Path No. 5-31194 Case # 1

This slide shoW~:~ a fairly ~rge lymph node whose archit ectural p;:.ttern is greatly distorted. The oorginal sinus~s arf1 of~an obliterated and where pre­lent are filled with large nu:ubers of lyn:ph:>cytae. and some reticulo-endothelial cells and t~ central portion of the lymph node is replaced by large numbers of lymphocytes. Under the very low po~<er tl:er e i s a sugg'lstion of giant follicle format ion. There is littl9 or no fibrosis. Good crach:!ng-off phenomena :J.re not seen. Under the high power exa'nination one flnds th11t the majority of the cells a.>"e lymphocytes a lli that sane of t-hsse a re L"'l ac~ ve mitosis, There are scattered eosinoohils, there are a lso sca'ct.,.red larger cells which are , I be­lie~, reUculUl!l cells. I n some areas there are ver·y lar,1e cells with definite­ly d:~rk purple cytopksm 31\d with irreg'llar ly shr.p:!d largs vesicuJ..:l.r nuclei and very pr ot:rl.nent nucleoli, I believe th.1se cells llre typl.cal Reed-Sternberg Cells. The differential diagnosis in this lymph node lies , I think, between three pos;ibilities:

1 . Hodgkin Is Disease of the paragranuloma type . 2, Giant follicle lymr,hos.:~rcoma , J . l..yr;l.phocytic lymphoe.arcoma. 4. Maybe 4th possible difftlrentinl problem, raactive hyparplaaia .

I think that we can eliminate reactive hyperplasia !or the following reasons:

l. I think th':>t the archlt.ecturu of the lymph node is completely dis­tort<ld.

2 . ~rminal centers, wh>i.>r e present, do not show ph01gocytosis by the reticulum cells ,

J , The lymphocytes which ! see outside the g~rminal centers are in act ive mitosis and appe3r abnormal ,

The diagnosis of giant follicle lymphosarcoma is not so easy to eliminate . There are app~ently sane gillnt follicles ;.!though thio picture is not ll pr e­dominant picture. There is little or no cr'l~!dng off phonomonon but there is distortj.on of tho architectural pattern and thzr e 'l!"e lymphocytes in mitosis which est.lblishes the d~.sease as a m1llgn<:nt disease of the lymph nodes . The presence of tho Reed-Sternoorg cells, I believe, eliminates thil gl. ':111t follicle l.'II!IJlhOma and the sm.ill lymphocytic l,.vmphosarcoma . If we , thaNfore, accept this as a liodgkin 1 s Disease, it would probc.bly be cb.ssifiad 'los the paragranuloma type. This would be my choice in the diagnosis .

FINAL Pi< THOLOGIC.:f,L DI AQIOSIS :

HOOOKINIS DISSASE (PARAGRANlJLOl.!.A TYFE)

A. 0 . SEVERANCE, M. D.

1

Case II' 1

Jacl<sen & Parker divide Hodgkin 1 s disease into thNe classes or typee pll.t~logical.ly. The first, Hodgkin's Disease , Hodgkin's p-aragra.nuloma; second, Hodgkin' e granuloma; t hird, Hodgkin' a sarcoi!IL\.

In the Hcxigkin' s paragranuloma type, one nevGr sees necrosis, infiltration of polym.rphonuclear leukocytes, or ~mrked eosinophilia, nor the fibrosis that one sees in t he granuloma variety. But by careful search one always finds wpi­cal Read-Sternberg's cells although som.,times not in very large numb~rs. Some­times the picture would resemble a. lymphocytic type of lymphosarcoma wer e it 110t for the Reed- Sternberg cells . This is tha type of Hodgkin 1 s Disease which offers the best prognosis, the longest life span, and the best response to treatment, If, however, this process in time merges over or bilcomes ontl of tro other types , then the prognosis is shifted to tha t of the types that arises. 'lhis form of Hcxigld.n 1s D1.sea.se occurs most frequently 1n the lymph nodes of the neck and onzy infrequently involves the lymph nodes 1n the mediastinum or abdomen or other internal org;ms , In the granulooo type, the lymph nodes usually occur in masses and ~~ve a firmer consistency end on s ection have a greyish-lddte appel rQOce wit h frequently a brownish tint or my be yellow foci of necrosis. It is always wiee 1n biopsying lymph nodes to select a lymph node f rom the neck or axilla, rllther than groin. Histologically, in the granuloma t7P8 there are Reed-Stemoorg calls and there is-e. greater pleomorphism of the otber cells. One sees mora eosinophile, sometimes more polymorphonuclear leukocytes and thore is much more obliteration of the architectural pll.ttc rn . Mitoses aro frequontzy sean, plesma cells s.re frequently sean Alld of course, the l.1=phocytes are nurrerous, Then the granuloma is also characterized usually by Mcrosis and fibrosis. In this type of Hodgkin's, the 4'mph nodes in the madiastinum and around ths aorta are m:>re frequently involved and there is a are~ter frequency of involvement of oth~r organs such a s spleen , liver, bonos, lungs, etc.

In the Hodgkin's a arcana type, there is gre o:~ter invasion p3st the capsule 111d again there are frequent areas of yellow necrosis. Microscopically, the t 111110r cells are two to t hree tilms tho s i ze of a normal lymphocyte and there are always num<>rous Reed-Starnberg cells with rnultilobed nuclei. Often these Reed- sternberg cells are numerous but in others they are few 'llld fllr between. The majority have a single large spherical nucleus with 3 promine.t:rt. nucleolus and resemble calls of reticulum call typ3. Mitotic figures are n\l1119rous . Normal reticulum cells arxi zymphocytes are scattered. Eosinophils a.re less t requentl,y seen, In this disease, other th..'m the }Jmph nodes, the liver and the &liBtro-intestinal tract aro frequentzy involved .

2

Case # 2

In this elide one sees the architecture of the lymph node completel y dis­tofte<~ . We see replacing the- lymph node, tumor cells which are diffusely scatter­ed throughaut and which show between and among them scattered reticulum celli. !be tumor cells are two to tllr ee times the size of a normal lymphocyte and they have a large round or oval vesicular nucleus with a small to moderate size nucleolus and 1d.th a pale eosinophilic granular cytoplasm, in small amounts, and with indistinct cell outline. The mitotic figures are frequent , There ie aoderate variation in the size and shape of the tumor cells . I ® not see any definite capsule to this lymph npde . It eeems to have been invaded and broken through by the tumor, I have ).ooked carefully and find no Reed-sternberg cells,

The differential diagnosis her e would lie between, I believe, a lympho­earooma, of the reticul um cell t ype , on the one hand and Hodgkin's sarcoma on the other ard one would possibly have to eliminate a metastatic carcinoms. The arrangement pattern is not tha t of an epithelial tumor. The cells are too diffusely arranged, there are no sheets or masses separated by dense fibrous atrana, I do not see any Reed-sternberg calls that I cs.n identify as such and I would therefore eliminate that diagnosis, The fact that there is not enough pleomorphism among the t umor cells is also against Hodgkin 1 s Disease , I wind up therefore, with reticulum call type of lymphosarcoma as my best diagnosis .

PINAL p,THOLOGIC..L DI,.GNOSIS:

LYMPHOSARCO!o!A (RETICUUJM C&Ll. TYPE) OF IIBDOMIN.\L LYMPH NODE. 1

I) J Ql<.\,-·( S f'1t E

.~ . 0 . SEVE!WiCE, M. D.

p.1th !lo , S-31587 Case # 3

We a re told that we are supposed to be studyL11g s secti on of small bowel but I cannot ident.ify it as such from tho sli:!e. AJ.otig o~e m:!rg!n of the tissue the re is an t!dge th st i s nec:-otic , hc'!lcrri'<-!gic o.d in adciition to it there is feca l rreterial , so this could be tna J::Jn·'>!l port:t.on o!' the l:oW~?l. Bo••el wall ho.-1ever, is conpbtely r epl aced b;r t·un•::- t ·cssue as i s the adjacent mesenteric fat . Along the outside of U.e mcs,mteric fat ~here is fibron and red cells on the sur .f11ce , The tumor is cha.ract.oriZ'Jd by diffuse infiltration of the tumor ce lls which are abnormally l 'lrgJ lymphocytes. I have looked care­fully and do not find Resd-Sterr.bt:rg C'llls . Th.a lymphocy-~e s a re JJ.\rg·" ' than a normal lyrrphocyte but are not as l arge as thos~ that we sa~: in Case # 2, t.he pathological numbe r S-3077!,. The tcmor cells in some po;•t.5.ons of this slide seem larg"r than ill other portions but yet not l ar ge enough for me to qu:l.to want to call them reti culum cell type of l~1T,phocyte.. Ylitotic f i guNs among these tlll:'.or cells is fa).rl:v frequent and thr·)\:ghoct the tUI:,or one sees a scatt.eril:g of r Gd cells; occ~ionr.l polymor~hor.ucle<-.r lelli:::cytes end occ<~sional s~l.l l;r.•phocytes ,

Our differential diagnosis here lies between the l ymnhosarcom3 of lympho­cytic type 1 and lymphosarcoma, r eticul um ccU tYPe, and P·)Ssibly Hodgkin I s Disease , The abs·mce of ilesd-Ster-noore cells •ri.ll , I thir.k , climin!l.te t!\e picture of Hodgkin's Disease . The uniformity of the ce-lls is agair.st HX.g'd .n ' e Dlsease . The size o.f the t umor cells suggests that we should stic!< to lymphocytic type of lymphosarcoma and not go over towe.rd the retL~ulum cell t ypa .

I like t .o divide the l ymphosarcomas i nto three main types:

1. The giant follic 1e type of lymphosa rcom'l, s oms time s called giant follicle lymphoma .

2 , l,ymphosarcoma, l ymphocytic type.

3. l,ymphosarcoma, reticulum cell type .

The prognosis I think is best in the giant foEicle type, nsxt best is the lymphocytic type and poor est is the reti culum cell type . '!':w r 3sponse to r adio­therapy is best in t he giant follicle typo: next best is the l~~nphoc;;-tic type :!nd poorest in t he reticulum cell t.11Je . Sort<~U.mes the gLmt follicle lyr.lrho­sarcoma ~rill merge ove r into the small lymphooy-~.:. c type of l.;fr.\phosJ.rcona 1\nd occasionally into the raticulum cell type , Tlw lympi:ocytic t ype of lympho­sarcoma is often indistingui shltble f rcm the chronic lymphatic l eukcr.lia 'lnd sometimes this type of l;ymphos~rcoma will t<m>:inate i n a clinical picture of lymphatic leukemill . Contrary-vd.se, som .. t:l.nes lymph>tic let:.kerda produces nodular infiltration in the organs which are similar microscorically to lympho­cytic type of lymphosarccma in the various organs . Th~ r eticulum cell type of lymphosarcoma is rrl.rn;.cked sometimes by cellular infiltrates in skin and other organs in cases of JWnocytic leukemia,

FINAL PATHOLOGICAL DIAGNOSIS :

LY!o!PHOSARCO!-'.A (LYMPHOCYTIC TYPE) OF S~'hl.L INTESTINE,

A, 0 . SEVERANCE, M. D.

4

Case # 4

This section shows a tumor which ·is composed largely of stellate-shaped and spindle-shaped cells in a loose and TnY'-'Omatous matrix in which we see scatte.red collagen and ret:l.culin fibers. These sp~.ndle-shaped and stellate­shape~ cells vary slig)1tJ.y to moderately in s i ze a~.d shape and they have a moderately chromatic irregularly shaped nucleus some are round end some are elongated and are triangular in shape. This loose a:1d myxomatous matrix in which the tumor cells are situated should stain and probably does stain with mucicarmine and most authorities feel that this is rnad.e up of hyaluronic acid. I did not find mitotic figures among these cells. In other portions of the tumor there is definitely fibrous-like tissue with elongated spindle shaped fibroblasts and much more collagen between the cells. The cells in these areas are fairly uniform in size and shape and~ain nc mitoses ar<> seen. In places there is a fairly thick band of relatively normal looking fibrous connective tissue forming a partial capsule to the tumor. Another interesting feature in the tumor is the peripheral location of cells 'around the capillaries in ~rhich the tumor cells are more compact an:l more striking in their appearance,

The possibilities in diffe~ential diagnosis in this tumor are :

1. FIBRO~!A. 2. FIBROSARCOMA. J, LIPOSARCOl4A, 4, MYXOl<!A,

Sinae there is so much myxomatous tissue present and cells are for the most part stellate in shape along with a wide expanse of mu<;inous like matrix between the cells I think we should be able to eliminate p~etty ~rell the FIBROHA. For the eamo reasons I: think 'lie should eliminate the possil:i lity ~f FIBROSARCOMA although this doesn1t necessarily eliminate the diagnosis of a !>!.ALIGNANT TUMOR. However, since the cells are fairly uniform in size and shape and I see no mitotic figures and since the lesion looks more like a HYXOl•IA then it does the other tumors I have mentioned I think probably ~re whould consider this as a HYXOHA. To eliminate a LIPOSARCOHA I would need a negative fat stain and I presume that this has oeen done, Grossly ~!YXOHA usually has a slimy gray mucoid nnterial in con­trast to LIPOSARCOMA which is a little bit more solid yet may shovr areas of myxomatous tissue, Th(l latter usually sh01~s some areas of yello>d.sh color .an:! I doubt if we sa\~ that here. I therefore ~rould prefer the diagnosis MYXOMA. 1 did not see any cells in this tumor 1·:hich I thought were 1.'\.poblasts an:! that is another point against LIPOSARCOI4A. As to the malignant feature of myxoma Dr, Stout in his fascicle on tumors of the soft part mentions the fact that these tumors recur and recur ami recur and aL'!Iost never metastasize and yet by their behavior and distinct invasion of near by tissues can kill a patient . He there­fore classifies them the malignant tumors but stresses the fact that they seldom metastasize. In this particular case we therefore can expect repeated re­currences unless adequate nnrgin of uninvolved tissue is removed when the next recurrence presents itself. This might mean sacrificing vital structures and if that problem is faced one might have to weigh the chance of a faint possi­bility of a malignant change against the use of the arm and additional opera­tions from time to time. It would seem the.t one should try to produce a local wide adequate excision at the next recurrence.

FINAL PATHOLOGICAL DIAGOOSIS:

IIYXOMA (RECURRENT) OF ARl•l, Reference-A. P . Stout fascicle on TUMORS OF THE SOFT TISSUE ARMED FORCES INSTITUTE OF PATHOLOGY ATLAS OF TU~!OR PATHOLOOY,

Case # 5

The tumor consists of tumor cells which vary tremendousl,y in si2e and shape and which have a diffuse haphazard arrangement pattern. There are lllll!lerous large l:d.zarre shaped monster tumor giant cells, many of which have ncuolea and many of which have two or three or more large irregularly shaped nuclei. Many of the nuclei are vesicular with scattered chromatin; others are hyperchromatic . 11itotic figures are frequent and many are of the bizarre er of atypical type. Cytoplasm is eosinophilic at times, again vacuolated. There 11 not too much intercellular collagen. In some portions of the tumor, there ue areas Of extensive necrosis.

In the Scharlach-R preparation many of the large monster tumor giant cells 8lld ~ny of the smaller tumor cells contain orange colored lipoid droplets. The lipoid material is in the tumor cells not noces:;arily associated with necrosis.

In the section from the metastasi s in the lung-A-149-54-the Scharlach-R preparation is positive. Here many or the tumor cells a.-·1d active mitoses con­tain the lipoid material. In the trichrome preparation of this metastatic tumor in the lung, the cells do no'.:. sho~1 thn bright rod one would expect in a rhabdo­JDYOSarcoma and I think this finding l ends support to the positive fat stain and lsaves us with the diagnosis of liposarcama.

FINAL PATHOLOGICAL DIAGNOSISr

LIPOSARCO!o!A OF POPLITEAL RIDION, RIGHT LID

STOUT, A. P.: UPOSARCOHA, THE 1-L<UGNANT TUHOR OF LIPOBLAST, Annale of S\lrgery Vol. 119, FBb-107, 1944.

NO'lEr This tumor likt~ mos t liposarcomas grossly hoo a slimy gray to yellow cut s~rface, both in the primary l esion and in the metastatic lesions in the lung . This particular tumor surrounded the f emoral artery and the sciatic nerve with resulting thrombosis of the femor.?.l and popliteal v~s with invasion of these veins by tumor. Stout classifies the liposarcomas inter

1, Well differentiated myxoid type . 2. Poorly differentiated my.v.:oid type . 3. Round cell or adenoid type. 4. Hixed group .

I believe that our tumor fits the poor ly differentiated myxoid type • •

A. O. SEVERANCE, M. D.

6

Path No, 21-55 Case N 6

Sections of the various rodules removed f rom the region of t he breast are similar, They shmv very lar{Je aci dophilic staining t umor cells with coarsely grll(lul.ar cytoplasm and lar ge vesicul ar r olJnd or oval m;.clei wi t h one or more prominent nucleoli . These t umor cells vary moderatGly in size and shape . They are characterist ically divided into elongat ed sheet s and co~ds by thin connective tissue septae in which vascular channels are seen . These t umor cells bear stri k­ing resemblance to those of a granular cell myoblast.oma except in this case the cytoplAsm i s dar ker eosinophilic and the cells very m0re in size and shape and show ~cattered mitotic figures , SO!ile of •mich 3re biz2rre or atypical. The reticulum stain brings out nicely the silver stain.\ng fibers which follow the trabeculae and separ ate t he t umor cells ir.to an epitheli?.l- like arrangement . There is little , if any, reticulum bet ween the tumor cells . A Scharleo~-R stain was done out of curiosj.ty and I •1as C!'llazed t.o find lipoid materia.l i n some of the tumor cells and bebteen some of t he t~:mor cells . Thi s has been reported by some authors . I believe t hat t hl.s t umor i s c.n exl).mple of t he t ype described by Christ opherson, Foot e , and Ste~tart l.n 1.952. Thqy r Gf e r to it as alveolar soft parts sar coma , Others, such a s Smet ana of the Al-'I? believe they are malig­nant non- chromati n paragangliomas , Th~se authors do not care to consider this tumor as a gr211ular cell myoblastoma. Ir.terestingl,y •.nougil, most of their cases were f rom the extremities . Recurrence was not..:d in three of their 12 cases and later they developed metastases .

I n vie,., of three poor results in Foot e and Stewart's seri es and the f atal termination of this case , one ehould consider the prognosis poor,

FINAL PATHOI.OOICAL DI AGNOSIS:

ALVEOLAR SOFT PART SnRCOMA OF l.E.G WITH HETAST .. SIS TO BREAST, BILhTERAL .

NOTE: A, P. Stout prefers to call this tumor an organoid type of granular cell myohla:>toma .

Roference t Alveolar Sof t Parts Sarcoma-Christopher son, lv. M. Foot e , F. vi. SteY~art, Cancer, Volume No. 5, p-100, January 1952.

A. 0 . SEVERANCE, ~!. D.

7

Case# 7

In this slide we see a portion of bone a.t one end o.f which the bone merges with cartilage 1dth an expansion of the bony cor·i·,ex by the cartilage , The cartilage is characterized by amorphous basophili.c staining matrix in which the cartilage cells shOOtting at times a clear a,,d at ot!'ler t i mes a slightly eosino­philic cytoplasm and a small, round, oval or slightly ir!"egularly shaped baso­philic staining nucleus . There is very little variation in size or shape of ~ these cartilage cells , I do not. see any giant car~t:lage tumor cells, Some cartilage seems to be forming in and around some of the small spicules of bone and along the cortex or the bone at one point. 1'ha bone marro1~ shows active hematopoiesis,

The problem here is >'lhether to consider this chondroma or whether to call it a chondrosarcoma , ~asses me as a benign gro~th ,

cartilaginous tumor a beni gn Histologically, the lesi on

I think that the lesion should bo treated by adequate and complete surgi­cal excision . 'llhe treatment should be the same ini tially whether or not t he lesion is malignant. The rate of growth, location, and x-ray findings are very helpful in correlating with the microscopic picture. I should be surprised if t his tWlJ)r metastasized.

PniAL PATHOlOGICAL DIAGNOSIS :

CHONDROMA OF FIFTH RIB, RIGHT.

A. 0 . SEVERANCE, M. D.

a

Case # 8

This slide 8hows a ver y inter esting tumor in which we see i n the background the per si s t ence of a tUJWr which I ~elieva is a neurolibroma. The neurofibroma portion shows areas of myxomatous tissue and dense ~:ollagenous type or connective tissue in which t here are elongated pointed m.cltli, at times being wavy in appearance . In some areas of this portion of tne tU!IDr the!'e arc abortive attempts at forming nerves; there are of course the usual number of blood vessels; fibroblast here are orderly in appearance and do not vary in size or shape and their generall :~:asemblanc e to Sch~tann cells is striking .

In the center of the twr.or ~1hioh i s surrounded by the n,;,urofibroma pat tern one sees an entirely di ffe rent t ype of histologi cal pi c t ur e , Here the t umor cells are more basophilic stai ning, and are charact e rized by round, ova l , elong­ateli and pointed nuclei. The latter have a vesicular appearance ~lith finel y distributed chr omatin and no prominent nucleolus . Cell outlines are i ndistinct and t he cytoplasm is pal e eosinophilic in s t aining quality, These tumor cells vary more in sizo and s hape t han those in the neurofibroma, are larger, and ahOlf scattered mitotic f igures. There is much less intercellular collagen be­tween these fibroblasts than t hose of the neurofibroma . I n some portions of this t wnor cent ral areas are occupied by very dense hyalini zed mat erial in which t he t UJWr cells are cro~.ded out . In some places i t has calcified . There are a f ew cells in this hyalin- like material that even suggest cartilage cells . I believe that this pic t ure here is due to degenerati ve changes occuring i n t he t11100r , The cellular are as I believe are malignant .

W)lat ar e the possible diagnosis?

1, NEUROFIBRDI1A . 2. NEUROFIBR0!1A IN ~IHICH MALIGNANT CHANGE HAS OCCURED AND VIE ~/OULD CALL

THIS A FI BROSARCOMA ARRISING IN A NEUROFIBR::JHA.

Although this is reputed to be from the tongue, I would el iminate a R!W!DOMYOSARCOMA on the histologi cal appearance and I would eliminate a l.fDCOMA and a IJPOSARCOMA and a LEIOMYOSARCOl-!A . I really think that this is e FIBOO­SARCOliA ARRISIOO ON A PREVIOUS k"EUROFIBRO!o!A . I do not want to let this t umor pass es a benign tumor.

I would anticipat e a recurrence in this parti cular patient since it was shelled out and yet t hat may not occur because the malignant portion of the t11100r is surrounded by rclat5_vely benign NEUROFIBROMA . One should of fe r a poor prognosis and with recurrence a much wider exci s ion is indicat ed .

FiliAL PATHOLOGICAL DIAGNOSIS:

FIBROSn..'l.COHA (~:ODERATELY WELL DIFFERENTii<TED) ARRISING I N A NEUROFIBROMA ,

Reference: Fascicle on TUJ.!ORS OF THE SOFT TISSUE, ,.ri.AS OF TUtiDR PATHOLOOY ARMED FffiCES INSTI TUTE OF PATOOI.OGY,

A. 0 . SriVriRI~~CE, M. D.

Cl.lSe # 9

The slide shows a circumscribed t'.llllor with considerable amount of dense fibrous connective tissue stroma in which there is a liberal grouping of small to mediwn sized masses of tumor cells and occasional gland-like structure reminiscent of sweat glands, There is no palisading of ~he nuclei along the basement membranes as in a bas'll cell epithelio:A•l, although occasionally sane of the cells along the basement membrane seem w !">.ave a clearer vacuolated cytoplasm. There is also a very eosinophi lic dense hyalin material along the basement membrane of some of these coll masses . Tumor cells t end to have a pale eosinophilic or at times clear cytoplasm end round or ovoid irregularly shapsd nuclei. There is a moderate distribution of chromatin and a very small nucleolus or often none at all. Tumor cells e.re unifonn in size and shape and mitoses are extremely rare. In some of the larger cell masses there are sml l islattds of hyalin tissue. Near the edge of the tumor are a few masses that sh<7< keratinization with intercellular bridges.

We we look at this microscopic slide, what other possibilities might occur to us? One would be a sweat gland adenoma, beca~:.se of the resemblance of the cells to those seen in sweat glenda . Two, one might think of carcinoma of sweat ~origin , While this is something that one must consider seriously, the uniformity in th3 size and shape of the cells and the infrequency of mitotic activity, mitigates against this possibility. I suppose one should think of a basal cell epithelioma but I believe the cells are too light staining and there is not too good palisading of nuclei along the basement membrane along with the usual number of mitotic figures one expects to see in a basal cell epi­t helioma. I can eliminate a squamous cell epithelioma because again there is too much uniformity of size and shape of the cells an:! absence of cellular un­rest although there is an occasional area of keratinization. I think squa.mous metaplasia in this tumor of sweat gland origin is accept able and does not rule out such a diagnosis. Neither does it automatically mnke a turner a squamous cell tUIIJ)r.

I believe that the evidence adds up in favor of adenoma of swe'lt gland type and one might use the term Hydradenoma, meaning a solid type of adenom.9. , and one migllt even use the term clear cell if one wants to differentiate still further. Gates, Warren, and '.·larvi, in their article on tumors of the sweat gland, in 1943, used the term Hydradenorna for solid tumors of sweat glaro type or as Allen calls it "solid adenoma". This t enn must be di stinguished from the h,ydra.denoma papilliferum which is a papillary growth frequently seen on the labia, perineum, and thighs. The solid hydratlenoma which we believe this is an exemple, is more frequently seen on the face am scalp and our case for tcrlay is rather unusual in its location on the dorsum of the toe, Thi~ tumor is, I believe, benign and I v10uld think that surgical tlxcision is sufficient , I caMrt be sure that it is completely excised because tumor cells are close to the eega of the tissue in my section, nevertheless, ! anticipete a favo rable outdome. These are rather rare tumors.

FINAL PATHOLOGICAL DI/,GNOSIS :

ADEI10MA OF SWEAT GLAND ORIGIN

' ~ T' ~

..1{/W'rJ }'- ........_ -v'

-( ( r,(,t).A \,

1.. 0 . SEVERANCE, M. D.

J

Case II 10

In this slide we see en encapsulated tumor composed of dark staining IPJ.1;ne.u<~ cells arranged in sm~l acini, elongated and irregularly shaped

, and in small anastomosing sheets and small clusters . I ndividual tumor have snall round or oval, fairly unifom, modorately chromatic nucl ei,

"'"'"·'-"·¥ with~ut nucl eoli, e.n:i 1 e. small amount of eosinophilic granular cyto-lfith indistinct cell outlines. Hitotic figures aro not observed. The

llt<trvenilna. stroma is dense , pink, hyalinized collagenous tissue at times appear-cystic where the collagen h!lS degenerated . The t·.1bes or gland- like structures

lined by t~to l ayers of epithelial cells . Sometim~s the inner layer is u.a""enea out and at other times it is more cnboidal. There is ll slightly more

appearance to the inner lining of cells. The outer layer of cells somewhat larger and they prolifer ate to occasi onally form t hese anastomo­sheets and cords . There are scattered lymphcytes in the strcrna. The

.~ooo>.uu is in the deeper areas of the corium in which nor.nal app-3aring sweat gla.nds are present. I am i.Epressed by the resemblance of the gland-like sti'Uci~ur· es to s~reat glands and believe that these cells are derived from sweat

The appearance of t:1is tumor, with its inflam1:1atory lymphocytes and anastomos ing s heets of sm~ll dark cells is suggestive of the variety of

gland adenoma which has been given a special n!lllle by Lever of myoepitheli-

Arthur Allen is not convinced tho.t this name Bs justified and he feels that adenoca of sweat gland origin is adequll.te and I tend to agr ee ~lith him. This is a benign turoot; . It is adequately excised . Ona should have nothing more to

about. While occasionally multiple these ar e usually single firm t umors 'Wi.tn.i..n the skin, and generally less than 2 em, in diameter .

FDML PATHOL(X;ICAL DI .. GNOSIS: E.C..C.\· il ' ' "'t I' ••

ADENOMA OF SWEAT GLAND ORIGIN (MYOEPITHELIOJ.!A OF LEVER) ,

A. 0 . SEVERANCE 1 ~4. D.

11

. .

Case II 11

The slide of Case # ll shows a small bit of tur.:or tissue in ~1bic h the tumor resemble plasma. C9lls . TI~ n'J.4';12.=.. a-:e £~!' :·~!"Jt:-:~ally sit.uateJ e~d show a

""'~'u.tely dark acido~h;__l.i~ sta.~ tllr:g p!:r1i~~~ t YvP J."~ cy~~~?:~sm. The nuclei are •••th•·• dark and chromaM.n mater.i :.J. io s: -l:. t,,~.;C. . Swt". cf t -h<l t.1m10!' cells have two nuclei. There is slight ve.riati?n in s~z,;, or tile cel'l_s attd c..I! o~.cadonal a4•cu•~c figures is seen .

Since the predor.U.nating cell i s a plast:'a ce U an::! since it looks like a because of so r;a:Jy plasma ceJ.;.~, some in ~to~es, s~me '<d.th two nuclei ,

and because we rave x,-ray e·Jidor.~e of r.:':3.'Vi.pl.:! d<lstr;;<:T.:!.'Ie ar.-:ss in bone, it is I believe , r easonabl e to arrin at a dinr;:1osis <::: mul vi. ple n>y<Jlo:na , Multlp1e 11,)'9lcma is a tum?r cccur:-i.."'lg pxedvrn:\.l'l!:toly !.!1 n:al9-; a."1d :;::-;te an~nors give a ratio of) to 1 with an ago g:-cup:!.ns g<J:'lerally of ~0 t:l 60 yelrtJ, Although recently I saw a plasma cell tuwm· of bor.s in a 16 year olrl famal.e <::hiJ.d . That , not·leWr, was a solitary lesion. \ofe huve here a 36 year olrt male 1 a li ttl<~ below the considered usual age of 40 to 60, s;.lt.~o;.~gh this should not disturb us . T!le bone s most frequently in':clved are vertebrc,e , ~elv:l:> , skuJ.J., rl bs, r.lavicle , and sternum. In this patit:lnt ~re have invol'""mllnt of t he s!ntJ.l, starnum, left clavicle and one vertehra. Occasi.onaJ.l;r in this disea.;e there DU\Y be a slleht increase in pllsma. cells in pe"-:i.p:1Crlll blood and cf coursa, th9 sternal ma~·<M aspiration usually shows i ncrease in pla~ma cells , mostly immature , Bence Jones proteins in the urine occurs in abou·t half of the" pati.onts. Frequently the total proteins in the blocd, espac~ally globuJire, ar.:J alevated . Those familiar with elect rophoresis sey the ra is a peculi11r doflnite pat tarn set up by this disease, Treatment is rad io-thero.py.

PI!fAL PATHOLOGICAL DIAGNOSIS 1

·'• 0. St;VER..NCE, M. D.

12

Case # l2

there a re t~ro pieces of tumor ti.ssue which are exactly s i milar. arranged in small cords, small clusters separat ed by connect~­

tissue strands or septa, and some mucinous .tegeneration of the stroma. The nw.vJ.<>uou. tumor cells have a fair amount of eo:-.inophilic finely granular cyto­

withwrt>lmd or f\Val nuclei which are mostl y vesicular either wit h or with-a smell nucleolus . There i s slight to !IP'de:·ate variation in the size and

of these nucl9i and cells. Some of the c•lls are larger and have vacuo­cytoplasm; others have a clear lighter st~ning eosinophilic cytoplasm,

times partly vacuolated. I do not gather thu i mpr ession that t he vacuoles lipoid-contai~~g, but rather that they may be a r esult of accumulation of

within the cell. I do not see any rri.t:>toi.c figures . I do not see any gland- like structures f ormed by tumor cella but in this tumor, at one point, i s a t rue gland composed of tall c olumnar cells t hat do not in anyway r e­the tumor cells proper.

I beli eve t hat t he di f fe rential diagnosi s hore lies between a carotid body on the one hand , a metastatic carcinoma, and possibl y a t umor of salivary origin, If ~ kne.r the exact location froJ~ the surgeon of thi s lesion we have a much less difficult problem in differenti al diagnosis , If this i s located a t the bifurcation of t he carotid ar tery then I believe t hat

ars able to bring ot:r diffe r ential d iagnosis do"!!'l to a choi ce between a oo.ruw.u body tumor on the one hand and a metastatic carcinoma on the ot her , The atee,nce of mitotic figures , the fairly uniform appaarance of the tumor cells and

arrangement of t hese cells into cords , separated by connective tissue sept a the moderate vascular ity of the t umor, suggest the carotid body t umor. On other hand 1 if this tumor is not at the fiifurcation of the carotid body end

it is up somewhere near the ear, then a tumor of salivary gland or igin i s t he realm of possibility. The presence of t ha t one gland l ined by nor­

col umnar eosinophilic cells has t o be given consideration in discussing possibility of salivary tumors. Near the edge of the lesion I see two gland-like structures which are similar t o the first one , They l'.Ould go

with t he salivary gland tumor t han the carotid body tumor. I shoul d t o see mor e capillaries in the f i brous septa between the cords and c l ust ers

tumor cells than I see here and I s hould like to see reticulum stains t o if t hat would help any . I n the f ascl.cle by Philip M, J..eCompte 1 in the Atlas

Tumor Pathol ogy of t he Armed Forces , Instituto of Pathology, the aut hor states he is familiar with one proved case of metasta$iS of car otid body tumor.

t herefore , believes t hat most of them shoulrl be consiltered benign and it is opinion that since it is mostly a beni gn t umor· , t hat the carotid a r tery

••no\LLCI not be sacrificed and that t he tumor should be excised as completely as 'I"""~''.L" without dan-.aging the artery . He emphas:!.zes the skilled technical pr o­'eedure involved to produce a good result . He, therefore, concludes that surgery

the t reatment of choice but skill in removal is paramount ,

No, ~)1)42 (continued) Case# l2

Now, if it is established that this tumor was removed from the parotid area beneath the rj.ght ear , then the gland-l.Lke s·tructures make sense and point to parotid gland origi n of this tU!ltor. This tumor is too cellular for a mixed tlll!lor but I believe it fits the pict'Jrc and description of an acinic or acinar cell carcinoma of the parotid gland as described by Fro.nk Foote and Edgar Fre.zell in their fascicle rm "l'umors of the Hajcr Salivary Ghnds 11 P- 120, Fig. 16) and 170. The sinusoidal septa betvreen the sheets and cords of tumor cells is similar to that of the carotid body tumor bd, much less marked in our case, I do not believe non- chromaffin peragangJioPic cells occur in the parotid region, The cytoplasm of the sa cells at, times is quite eosi nophilic and coarse­ly granular and this goes better with a salivary gland tumor,

This type of p~~tid tumor is considered in the group of low grade mali g­nant types, occurs frequent!¥ in women, rrore comon in the 40-60 age group, is prone to recur and grows sluggishly, Out of 21 cases at Merr.orial, three cases died; one of local disease, and tm> of distant metaGtases. Only one had cervi­cal node metastasis. These metastatic cases l ooked similarl y microscopically to the ones no.t metastasizing. Dr. Stout gave me valuable assi stance in this ease and ha concurs in the diagnosis .

FINnL PnTP.OLOGICAL DIMh'IOSIS:

:.CINIC CELL ADENOCARCINOHA (ACINAR CELL CARCit;m!A) OF PAROTID.

A, 0 , SEVERANCE, ~1 . D.

14

Path No, S-3127'1 Case # 13

This sect:.ion of breast tissue sh'lwE rm.:ltiple sw.all tumor foci sit uated fairly close together but with i ntervening !'e.t- and f'.brous tissue between some of t hese tumor nod11le s . Tne tumor i mpresses me a~ growing m'linly 1'11 thin the ducts, and f i lling the ducts ~tith t umor ~ells forming seconr\a ry acini. In comparison with t he cells of s0'1le normal duc!.s r:ear :>y these tumor cells ar e larger and li@llter s ta;!.ning. Th!!y va:-y s lightly t o i!!Ode!"e.tely in size a!li shape. The indi·ridua l tumor cells have pale, eosinophilic finel,y gr'lllul a r cytoplasm and V'3sicular round, ova l or slight ly irrega .Larl y shaped nucl ei, o£ten rtith' a prominent nucleol us and somstimos totith tt~o or t hree nucleoli . Mitotic f igures are f airly frequen~ , sometimes two or more being secln in the single high po>ler fi eld b>.u:. the average i s !!.bout one . There is an occasional llitotic figure of t hffi! atypical or bizar r e type . Often the masses o£ tumor cells which seem t o be replaci ng the duct s are ve r y close t ogether and saparated by only fine connective t i ssue bands.

The d1£ferential dia gno,;is hare lies between w intraductal carci.norna on one haM and a benign epit-helial hyper plasi 'l on t he other, I believe t he eVi­dence i s more in f avor of t he i ntra<:uctal ca r ci noma . 1'his evidence is; firs t , the l arger size t hm I think one s!1ould hnvo in a ben:ign l esion; second, the variation in si ze and shape is mo:ro pronou . .>1ced than one should expect. in a benign hyperplasia; thirdly t her e are ~re mitotic figur es, some o£ which a r e atypical, t han one •..rould. expect to find in a benign lesion; i".nd finally, I think the process is more e:x:t..ensi ve tr.an perhaps one would expect in a benign hyparplasia of the duct epithe l ium.

The t reat ment I would think all would agree on i s the r adical mastectomy, because I am one of those who folio.~ Or, ~;rthur Purdy Stout r s dictum that once the diagnosis o£ cancer is Jllllde, a radical mas tectomy i s manda tory. I should ant~cipate that aft er tho r adical mastectomy has boen done that we might expect to find negative axillary lymph nodes i n this case , If so, I ·110uld. expect a very £avorable prognosis .

FJ.N.\1 P~THOJ..OOICAL !)IAGOOSIS I

lN'I'RADUCTAL CARCI NOMA OF BRE:.ST ,

Path N9, S-25729 Case # 14

In this slide we see a tumor of ·thti! ovaJ.·y in which the ovarian stroma is ptshed off to one s;_de by the tame:- calls . Thcs~ ',;-..::ror cells are arnnged in ?arying sized acini and snvU.l to medi:;;~ E :i.z~c'. r.vts::>e::~ and a..'1ast0mos~ng eheets of cells. The individual tmnot- cells v<J:ry con :;:;ri~:.·alJ),y :i.n size and shape ;)nd frequent monb~er tumor giP.nt c:el.l~ e.re ob3er·reG. l'he;;e ·C.umor cel ls hava abundant, coarsely granulf';· eosinoph:i.li.c cytop).asm mod J.arce Vt:f:licular nut: lei, varying from round, to oval, e;:Ii sor.wwhe.t irragular j,n ehape. Coll; tend t o have a large promnent nucleoJ...tS . l n some areas the tufi,.;r cell I! s:.o.,, tremendc>us vari .;t,ion in size a:ld shape of both cell and r.ucleus. Sc3.ttere1 t>iza::-T€ :'0:-:-J!I.s of mitotic activity ere see!l >li.th some freq.;ency. There is a small to mc::lerate <11110unt of supporting connective tissue stroma. In s cme places well-for r,pd gland structures are very easily made out .

Our differential diagnos.ts lies between a prirno.ry carcinom:1 of the ovary, of the adenocarcinoma type t r so-·caJJ.ed soJJ.d carc inoma of the o :ary, and metastatic carcinotll.a to the o-.•c.ry from some ot.her org'ln. O!le should also con­sider briefly a granul~sa cell turr.or, but I bt'lieve that t his t UJT.Ol' c .ln be &limin!lted on the basis of large tumor size noted here, t•he variabion in the size and shape of the tu.....,r cells, and on the general arrangement oattern . '!here were no functional changes in the patie!'lt to suggest a possible granulosa cell tumor. The posdoiJity of a metastatic carcinoll'.a, is more difficult to eliminate but the history does not sugge~t that this pntient had trouble else­where and while metastasis from another organ i s possible , I believe that the chances are much better that this is arislng ;,n the ovary. I think it would tit NOV!lk l s classification of a solid card.nor.u. of t he ovary, of tfta adeno­carcinoma type, or it would f all into t he chssification of seroan~ plaatll.c carcinoma as used in the Atlas of Ovarian Tumors by Gcnuna Barzilai. One might c;ll :.t his a Grade III, adenocarcinoma ancl let it so at that if they so wish. !!ova.'< 8 3.YS that early in development these tumors tend to be unilateral, but later on they become bilateral. Barzila.:i believe~ t.ha~ about 9Cfl, of t hem are bi.'::steral. 'The tumor cells from this ovar;' m;y spread do•,,n tile Fallopian tubes art! implant Within the tube or endometrium; it mey extend b'.t direct extension tr.rough contact to other noarby tissues; i·~ may spread through the capsule of the ovary and implant t hroughout t he peritoneum; :tnd1 it coul::l a l so of course, 8pread by way of lymphatic vessels to the lymph nodes in t~1e pelvis; tumor cells may go by lymph:~tics to the other ovary; a.'1d fi na l ly diutant organs such as liver , lungs, pleura, ribs, Md other abdomin'll organs may be involved . I r.!lve even seen a supr3.clavicular lymph nods invol''"d wi.th ovarian carci.nom. Had it been known at the ti.-ne of operati on, or su flpected, or had a ftozan section been done , and the diagnosis of nalignant ovarian tumor established , I believe the other tube and ovary should tuve teen rerr.o·1ed a long ~oti ~h the present tube, ovary and uterus . Prognosis is not gcod on this poorl y difie:-entia.ted carcino­ma, I see no reason for post-operative r adio-therapy if radi cal surgery has been performed,

FiliAL PATHOLOGICAL DI .. GNOSIS:

ADENOCARCINO!o!A OF OVARY .

I! . 0 . SEVERANCE, H. D.

16

Case # 15

As we can see from the slide there is some normal submaxillary gland on edge of the tumor. One can even see a fe'tl eroups of tumor cells actively

the adjacent submaxillary gl and. '!'he tumor is fairly ~1ell circum­;acl'J.lJea but not encapsu.la t ed. There is a Jax-ge amc,_;:r~ of very dense hyalinized

cormective tissue forming the stroma and in it one sees tumor cells seem to be arranged both in cell ular masc.es 2.nd sheets, and also in the

fom of small clus ters and small acini. Sene of t he acini s hov1 secondary acinar formati on, The tumor is occasionally seen complete ly surrounding a nerve bundle. All occasional normal duct of this submaxillary gland is seen persisting in t he middle of the tumor . The stroma a:·cund the tumor sho~rs a slight infiltration of ~phocytes, At one point t he tumor i s pushing into the l umen of a blood vessel but seems t o have pushed the endothelium in front of it too . In some of the larger m~sses there is secondary degeneration vrith hemorrrage . The tumor cells seem to have secreted a pale basophilic staining mat eria l ~1hich I believe is mucin·ous in nature and i n a mucicarmine stain would be mucicarminophilic. The epithelial cells lining some of these glands a r e very th:'.nned out and flattened, while others are rather thick and large and have eosinophi lic, faintly granular or at times v·acuolated cytoplasm. The round or oval nuc l ei, are either vesicular or moderately chromatic, A small nucleolus is occasionally i dentified. A f e>r mitotic figures are noted . There i s only light to moder ate variation in the size and shape of these tumor cells.

As I look at this tumor the differential di agnosis, I believe would i nclude a mbced tumor, salivary gland typa; adenocarcinoma mucinous type, and perhaps a cylindroma and finally a muco-epidermoid ca rcinoma . I believe t hat we can ~ckly eliminate t he mixed t umor because of the invasion through the parent capsule into the adj acent submaxillary gland, and in t he ~ray the tumor in­filt rates and surrounds ne rve bundles, I believe it adds up t o a malignant tll!llOr. The cylindroma tumo r pattern does not appear in thi. s lesi on. We do not see t he small more ba sophilic staining c ells surrounding large r areas of mucinous materi al as a lumen; and furthermore., I believe that ther e is a little more variation in the size and shape of t hese tumor cells t han is seen in cylindromata . There are no epidermoid feature s of a mucoepidermoid carcinoma, although I understand this is not exactly necess.:tty for t he diag nosis .

This tumor is very much like a pi cture of a t umor in i.e kerman 1 s book on Surgical Pathology, P-371, Fi g . 426, in ~<~hich he r efers t o it as a "carcinoma of the hypernephroid type " . It sho1-1s the same l arge clear cells vii t h mucinous 111aterial, I beliew that it woul d be sufficient for us to consider this as a IIIOderatel y well diffe.rentiated carcinoma, mucinous type, of salivary gland.

In regard to t reatment, I believe tha t I l<oul.d r ecomm<:md r adical surgery and consider neck dissection only if l ymph nod0s a re palpabl e . I I'.'Ould not ex­pect radio-therapy to be of very much value in this t ype of tumor. I know that

17

Path No. ~32237 (continued) Case # 15

in Ackerman and Regato •s book on cnncer they quote a series of cases by Ahlbom in ·.ru.ch he felt tha t good results occurred following radical surgery and radio­therapy, Personally, I t hink that I should stick to r adical surgery.

FINAL PATHOLOCICAL DIAIJ.lOSIS:

CAJ!CINO!-!.A (MUCINOUS TYPE) (MODEfu.TELY WSLL DIFFERENTI"TED) OF SUBMAXILLARY GI;JID, LEFT,

A. 0 . SEVERANCE, H. D,

Path No, 3228-54 Case II 16

This case is one of a tumor of the parotid salivary gland ~1hich has a striking papillary arrangement. The tumor cells are seen f orming the papillary projections with slight supporting connective tissue stalks in which some capillaries are seen. The tumor cells covoring these papillary projections ahow moderate "'Tariation in size and shape and the t tuno;· cells have finely granu­lar eosinophilic cytoplasm and vesicular round or OYal nuclei with prolllinent nucleoli. There is moderate variation in size and shape of the nuclei ard some nuclei are hYJ:erchromatic , Some of the tumor cells have vacuolated cytoplasm ld.th a nucleus pushed off to one side, l•li totic figures are infrequent . In some areas the tumor cells form acini which are filled with a pink amorphous material and are lined with a light blue material 'ffhich suggests mucinous material.

In the mucicarmine stain which was made t- settle this point , the materi al in the acini and ,_n the vacuoles of the tumor cells is mucicarminophilic . I n some of the acini, this mucinous material and pink amorphous material was so pra:d.nent that the t hought of a tumor of thyroid gland origin entered my mind. I believe the mucicarmine stain has elilninated that possibility. There is der.sa hyalinized fibrous connective t issue in the center of the tumDr and in some of the papillary projections ard in the stroma one sees considerable heoosiderin pig)llent deposition . Scattered round cells are noted in the support­ing strOJlla. The tlllllOr is actually found invading -the parotid gland tissue, A trichrome was done but added nothing to the stu:iy, There are no epidermoid Ceatures noted in any Of the s:bc slides stud.i.ed, \·lhile the tumor looks well circumscribed, it is not encapsulated because there is invasion through the capsule in the nearby parotid,

I believe we are dealing with a papillary carcinoma of the parotid gland, Clinically the thyroid gland was not involved in a.'"!y pathological change and the mucicarmine s tain, I think, would help eliminate the thyroi d as a source of metastatic tUJI¥)r and so we can consider the tumor primary here. Both Stout and Ackerman refer to the well-differentiated papillary adenocarcinomas as rare and slightly less malignant forms of salivary gland tumo;-. Ackerman in his book notes that they may form mucin and he says that the photographs are oot like the ones we are sttrlying, The treatment of choice is radical surgery but irradiation therapy may be Ulled for those who are definitely inoperable . The cylindroma form of carcinoma of the salivary gland responds somewhat better than the other types of carcinoma of the salivary gland , These car­cir.omas metastasize by both blood stream and l:'f"!!lphatios,

FINAL PATHOLOGICAL DI .. GNOSIS :

P.PILL.UlY I.DENOCARCINOI-!.. OF P...ROTID GL.\ND,

A. O. SEVERANCE, M, D.

19

Case # ~7

In the low power one sees a portion of thyroid in which there is a tumor that is largely <>urrounded by dense fibNus capsule, The tumor nodule

-·•••'•~ of very large, acidophilic tumor cells whJ.ch fonn thyroid follicles flll')'llll! moderately in size, some being fairly lm.'gc and others very small.

the follicles have eosinophilic colloid but a few appear empty, These IJ.a'~l.nc,;J.y eosinophilic tumor cells vary slightly to moderately in size and

and some of t~em have a fairly large dark, moderately chromatic nucleus others have a smaller round or oval vesicular nucleus ·.dth a prominent

mue:J.eo:Lus I did not see any definite mitotic figures. ·,ihile the variation the size and s0111etimes the shape of the tunor cells, esi>ecially the nuclei , disturbing, I am reminded of a conment by Shields Warren in a Columbi'l,

lliiiSO•uri Seminar, that the adenomas of the thyroid can sometimes be very disturb­in appearance without actually beL"tg malignant, An interesting point in this

is the invasion by these thyroid t ~ mor cells into the capsule and at one I saw what I considered lymphatic invasion i n the edge of the capsule by cells, ... t one point the tumor cells appeared to have broken clear through

capsule , i<t another point there is another small nodule of similar cells in adjacent thyroid , just beyond the c3psuls, This is either another separ ate

llodula or possibly an extensi on of the larger one to the capsule to f onn a .aeeondary satellite nodule .

I think on the basis of the invasion of the c apsule and presence of tumor , in wha t I called lymph<ltics, we should consider this to be a malignant

10nange in a Hurthle cell tumor and should call it a carcinoma of Hurthle cell This is a fairly well differentiated t)'J)B of carcinoma so that metastasis

be expected to be somewhat slow and it may prove several years before there a recurrence, Recurrence is especially common in instances where the surgeon

tnucleates the tumor nodule . Unilateral lymph node metastasis may be expected ICli:IBti.me in the fUture , if it occurs . These tumors are said t o be more COIMlon 1n vanen than men; in this case it is a ma l e , Some authors o;ould advise t otal tllyroideetomy, others complete hemithyroidect OIIIY• Some would suggest rather prophylactic radical neck dissection, whereas others would adYise a radica l

dissection only if there is clinical evidence of metastasis . In t his particular twwr, I believe that a complete hemithyroidectomy ;d. th 11 par t. of the isthmus is all t hat I would advocate and I would wait for r adic.<J.l dissection until eVidence of clinical metastasis appeared.

"""""" (HURn!U COIL TYPO) OF THlROI:· j j> & .

)~~ A, 0 . SEV.::R<\NCE, H. D.

:;

Case # 18

The brownish area descri bed in the gross shows on microscopic study, large staining tumor cells ~lith finely granular cytoplasm artd often with

pi8lllent granules which are presumed to be lipochrome pigment. The cells have a nucleus which varies from round to oval and contains finely

chromatin and often a prominent nucleolus. The cell outlines are ur•,~u.a.a•· and the tumor cells vary moderately in size 1 more so in shape, and

tend to stream out and be elongated, In the Scharlach-R prep;~ration, many-the t\llll)r cells show a positive reaction for lipoid materia, which is fairly

in same portions of the tumor, The tumor cells are separated at times bundles of fibrous connective tissue into relatively large masses and

in turn s heM smaller anastomosing sheets and cords of cells, Some re­hernosiderin pigment is observed in the tumor.

The resemblance of these cells to the normal interstitial cells of Leydig in the testis is very striking ~tttotic figures are not seen . In 1951, and myself reported a case of bilateral interstitial cell tumor of the

and at that time, our review of the literature disclosed Jl cases of ~t•er:~titial cell tumor of which 21 were in adults and lG were children, three

which metastasized. Three of the adult tumors were associated with The case we reported was the fourth case of a bilateral inter­

tumor reported in the literature. In the occasional case that has for hormones, urinary gonadotropins were found elevatec;! and the ,\schheim-Zondek test was strongly positive and in others the

and tre 17 ket.o-steroids were also elevated. In boys, this type of usually results in a precocious development of the child, Most of these

are benign. Dr. " • P. Stout does not knew how to recognize a malignant one scepically. Treatment is surgery,

Prognosis in general is good. In one series o'f 27 cases collected, J died the disease and one sho>ted a metastasis 9 _years post-operatively,

Ill'l'ERSTlTinL CELL TUMOR OF TESTIS, RIGHT,

"• 0 , SEVERloNC~, tr., D,

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