PROTOCOL

FOR

MONTHLY SLIDES

December , 1958

TUMOR TISSUE REGISTRY

LOS ANGELES COUNTY HOSPITAL

NOTE: There are only six (5) cases with twelve (12) slides presented in this Conference. We have .prepared slides on the original material and on the fo1lm~-up submitted on each case. This latter slide is identified uith an "F" after the case number .

IZ~t

CASE NO . 1

ACCESSION NO. 8060

NAI-l!: M.N. AGE: 43 SEX: Female RACE: Cauc.

CONTRIBUTOR: J. D. Kirshbaum, M.D.,

December, 1958

OUTSIDE NOS. C-1025-55 ~1-3510-58

San Bernardino County Charity Hospital, Sen Bernardino, California.

TISSUE FROM: 1, Thyroid - surgical specimen, lP .Liver and spleen - autopsy mat erial.

CLINICAL ABSTRACT:

HISTORY: Entry was made to the hospital on May 27th, 1955, with com­plaints of sudden onset three months previously of a growth in the neck. The local physician had found a BHR of plus 50 in March, 1955, and placed her on Lugol's solution and Thiouracil, but without benefi t , Subsequently there was nervousness, wealtness , cryl.ng episodes and heat intolerance, In spite of medi cation, the mess in the neck continued to enlarge and one month before hospitalization, difficulty in eating and breathing was noticed. lbere had been no weight l oss. The pest history revealed that the patient had been a gr avida VII, para III and AB IV. The last menstrual period one weelt previous­ly had been regular.

Physical examination disclosed pulse 72 and regular, blood pressure 120/80 , respirations 16, and a prominent diffuse, S}~etrically enlarged thy­roid which moved with Sl~allowing , There ~~as no bruit.

LABOP.ATORY FINDINGS: PBI was 6, 5 micrograms, blood cholesterol mgm1. and ~m minus 30. Chest X- ray ~1as essentially normal.

For three weeks pre-operatively, propylthiouracil,lOO mgm every 8 hours and Lugol's solution was given .

SURGERY: On June 17th, 1955, a total thyroidectomy was performed, Lymph nodes were removed on the left side. In removing the thyroid, the trachea was found to be invaded.

GROSS PA'lliOLOGY: The thyroid was diffusely enlarged, hard and pinkish salmon in color.

FOLLOW-UP: lbe patient had low serum and ur inary calci um following sur gery and developed muscle cramps . She was placed on calcium supplements orally and Hytacherol. Radiation Sl!IOunting to 300 r was given to the nec!t, but was discontinued because of differer.ce in opinion regardin~ the nature of the lesion.

Patient expired on Augus t 16th, 1953.

AUTOPSY FINDINGS: Autopsy showed bilateral pleural effusion with massive left lower l obe atelectasis, hydropericardi um, chronic passive con­gestion of viscera. The l iver, spleen, pancreas and ileum, as well as per i-aortic, per ipancreatic, peri-esophageal and inguinal lymph nodes were i nvolved by tumor.

CASE NO. 2

ACCESSION NO. 9936

NAME: J .P. AGE: 48 SEX: Male R.!'.CE: C,auc.

CONTRIBUTOR: Frank R. Dutra, M.D. , Eden Hospital, Castro Valley, California.

TISSUE FROM: 2. Ribs - surgical resection. 2F.Adrenal -autopsy material.

CLINICAL ABSTRACT:

December • 1958

OUTSIDE NOS. S-9305- 57, 57-A-157.

HISTORY: Onset of progressive pain occurred in the left shoulder region in August, 1957. I~ December, 1957, after a bout of influenza there was a ~relve pound weight loss over a period of three ~reeks . Entry was made to the Eden Hospital on December 15, 1957.

PHYSICAL EXAMINATION: The blood pressure was 140/90. The chest was clear. Tenderness was present in the left axillary region over the axillary portion of the third rib. There was marked clubbing of the nails of the fingers and the patient stated that this was a familial trait that had been present since chi ldhood. X-ray examination revealed destruction of the axil­lary portion of the third rib of the left side.

SURGERY: On December 16th, 1957, thoracotomy was performed lnth re­moval of the rib tumor.

GROSS PATHOLOGY: The segment of chest wall included portions of three ribs. The lower and upper ribs measured 7 em. and 12 em. in length, while the center rib was 13,5 em. in length. There was a fusiform swelling of the cen­ter rib with extension of the swelling into the intercostal muscles on each side. The region of swelling was 6.5 em. in length and ·the pleura and perio­steal tissue l~ere elevated so that the swelling was up to 3.5 em. in thick­ness and 4.5 em. wide, Section revealed granular, gray tissue with visible mucous and pale yellow areas of necrosis, The pleura overlying. the deepest part of the· tumor was intact . Ho~rever, a 0.5 em. in diameter satellite nodule was located subpleurally near the large tumor .

FOLL0l~-UP:. Postoperatively, the patient did ~7ell until December 19, 1958, when he developed hemiplegia . The following day there was substernal pressure and difficulty in breathing. On December 21st, phlebothrombosis was present in the right lower extrer.tity. The patient expired on December 21,1957.

AUTOPSY FINDINGS: ''Postmortem examination revealed that the primary neoplasm was carcinoma of the adrenal cortex·. Both glands were largely re­placed by tumor which was thought to have arisen independently in each, The absence of evidences of Cushing's syndrome, of hyperalderonateronism and the absence of Croolte' s changes in the cells of the anterior lobe of the hypophysis indicated that the neoplasm 1;as not producing hormones. The right adrenal weighed 227 grams while the left adrenal weighed 57 grams and was two- thirds replaced by tumor. No other focus of tumor lJas found. "

"The terminal events 1~ere prefaced by the develop­ment of phlebothrombosis postoperatively, and the outcome was dependent on the presence of a patent foramen ovale. Emboli from t he veins of the lower ex­tremities lodged in vessels of both ltidneys and in the brain. An embolus also occluded the artery of the posterior basilar segment of the lower lobe of the ri ht lun • "

CASE NO. J December , 1958

ACCESSION NO. 8252 OUTSIDE NOS. M2864-55,

NAl1E: J . L. G. AGE: 38 SEX: Hale RACE: Negro

CONTRIBUTOR: W. W. Hall, M.D., Mercy Hospital, Bakersfield, California.

TISSUE FROM: 3. Tumor, right m1ltle, surgical specimen,l95S,

HJ286-57

JF. Tumor, right m1kle, recurrent, surgical specimen,1957.

CLINICAL ABSTRACT:

HISTORY: A tumor had -bee11 present beneath ·the right malleolus for many years. In the previous two years it had grown with some rapidity and on examination presented a mass 3.5 em. in diameter, protruding out beyond the level of the malleolus, It appeared fixed to the underlying tissue and was rather firm but somewhat elastic.

SURGERY; On October 18, 1955, the tumor of the right ankle was incom­pletely excised.

GROSS PA'l'HOUlGY: The 2.5 em. finn mass was encapsulated on its super­ior surface, but was ragged on its inferior and lateral margin. The second irregular piece of s~ilar tissue measured 1.5 em.

FOLLOW-UP: The surgeon bad planned to make a more complete re-excision of the tumor. Since it was classified as benign this was not done; For a long time the tumor did not appear to grow. However, in 1956 it gradually increased in size until it interfered \lith activity, There ~1as moderate, but not constant pain .

In June, 1957, entry was made to the hospital after the tumor bad gradually enlarged and protruded below the right external malleolus until it interfered with activity. x~rays showed bony erosion.

SECOND SURGERY .in June, 1957, showed the ~umor to be widely adherent to all bone, capsules and tendon structures and to "go through" the astragu­lus through an opening l em. in diameter. The tumor was as completely re­moved as possible, all surfaces being cleaned and scraped.

When last seen in t1ay, 1958, there was no pain in the foot, increase in size, or disability. The mild pain and discomfort did not interfere with his work. Examination showed satisfactory healing of the wound with no evi­dence of enlargement or tumor. x -rays revealed that the defects in the bone were healing and were filling in with bone and callus. There was no evidence of progression or other reaction.

CASE NO. 4

ACCESS ION NO. 8582

NA}IE: L.C. AGE: 55 SEX: Male RACE: Cauc .

December, 1950

OUTSIDE NOS. R-537· 56, A-58-91

CONTRI.BU'IOR: ~1. W. Hall, M.D. ,-Surgical specimen. B.L.Benjamin,M.D,,-Autopsy D.R.Dickson, M.D. material. Santa Barbara Cottage Hos-

Mercy Hospital, Dakersfield, California.

pital, Santa Barbara, California.

TISSUE FRClol: 4. Left antrum. Feb.20,1956, surgi cal specimen. 4F. Adrenal, autopsy material.

CLINICAL ABSTRACT:

HIS'IDRY: Catarlh ha4 been present for many years and in October,l955, episodes of epistaxis began . On December 25th,l955, there was sudden onset of pain in the left eyebron accompa.,ied by numbness on the left side of the face . The numbness subsequently subsided,

SURGERY: On February 20th,l956, a left antral lesion was biopsied and polypoid tissue was removed from the nose as an office procedure.

GROSS PATHOLOGY: Some of the nasal fragments were polypoid and appeared friable, fibrinous, clot-like or necrotic. They varied from 0 .3 to 1.0 em. in diameter. The tissue fragments from the left antrum varied from 0.4 to 0.9 em. in diameter and were hemorrhagic and friable.

FOLLOW-UP: Following suraery, a six weeks course of X-radiation thera­PY was given. Entry was made to the Cottage Hospital in Santa Barbara in March, 1956, with complaints of anorexia and nocturnal episastric pain. Physi­cal examination revealed heptomegaly, severe anemia, pathological fracture of the right fifth finger and subcutaneous nodules of recent occurrence in the anterior thorax, anterior abdominal wall and sacral region, On April 4th, 1956 , a subcutaneous nodule of the thorax was excised and showed the same cytology as the antral tumor.

Patient was treated with a four day course of nitrogen mustard, Predni· sone and blood transfusions, The subcutaneous nodules completely disappeared and the pathologic fracture through the lytic lesion in the right fifth finger recalcified.

In the following two years, he returned six times complaining of abdomi­nal pain, back pain or new crops of subcuta.1eous nodules. Each time a course of nitrogen therapy was Qivetl and the pain would be relieved and the nodules disappear. The liver was enlarged in May, 1956, but decreased in size until terminally. Anemia ( Rbc 2.9 m ) ~ras present in ~lay, 1956. The Wbc was al · ways within normal limits until terminally when a few cells that appeared ma­lignant were in the smears.

Despite the complaint of pain in the back, repeated roentgenograms never showed bony metastases. The cervical or other superficial lymph nodes were never enlarged. The nasopharynx was clean until a small friable bleeding area was noticed on May 29th, 1958 a.,d biopsied. Terminally there was severe epis­taxis and gastro-intestinal bleeding which could not be controlled, The pa -tient expired on September 5th,l958.

continued·

-2-

CASE NO. 4 - ACCESSION NO. 6582 - continued.

AUTOPSY FINDINGS: At autopsy the enteric canal was filled with blood. ~o gross naso-pharyngeal tumor could be found, The liver was en­larged to 2200 grams and contained several soft, mushy, gray-red nodules up to 12 l!llll. in diameter. The enlarged spleen weighed 710 grams and was free of nodules. Both adrenal glands contained mushy, gray-red nodules varying from 0.3 to 3.0 em, in diameter. Bone marrow was hard, mottled pinlt-white, with­out local lytic lesions. The lungs were free of tumor,

CAS!l NO . 5

ACCESSIOli NO. 9649

NAME: B.A. AGE: 46 SEX: Female RACE: Cauc,

CONTRIBUTOR: John J, Gilrane, M.D., St. Luke Hospital, Pasadena, California.

December, 1958

OUTSIDE NOS. 3149-57 1064-58

TISSUE FROM: 5. Ovarian tumor, resected September 19,1.957, SF. Sigmoid tumor, resected April 7,1958.

CLINICAL ABSTRACT:

HISTORY: Continous discomfort bad been present in the lower abdomen for one week and for three weeks discomfort occurred when bending over. There had been no pregnancies.

SURGERY: ·On September 19, 1957, an ovarian tumor was biopsied. This was followed by a bilateral salpingo-oophorectomy, total hysterectomy and incidental appendectomy.

GROSS PAniOLOGY: Both ovaries were enlarged and cystic . One measured 12 x 18 x 27 em., and .the other 6 x 9 x 3 em. The external capsules were smooth, The largest cyst had a diameter and was lined by a 2.5 em. rim of gray-yellow necrotic tissue. Some of the smaller cysts were lined by light tan papillary tissue . A fe\1 had smooth thin ~1alls and contained clear gela­tinous light yellow fluid, The tubes were intact and patent.

The uterus contained a few intramural leiomyomata. The lumen of the appendix was obliterated i n its distal third,

FOLLOW-UP: On April 7, 1958, sigmoid colectomy was performed because of G.I. obstruction,

GROS·s PATHOLOGY: The 19 .5 em. segment of colon was dilated up to 16 em. in circumference in its pro1timal portion. Extending 2 em, above the distal surgical mal'gin was an annular napldn ring neoplasm encircling four-fifths of the bowel wall and extending in the dorsal ventral axis for 3.8 ems. The tumor penetl'ated the mesocolic fat and extended to the regional lymph nodes.

CASE NO. 6 December , 1958

ACCESSION NO. 9733 OUTSI DE NOS. S-3212· 57, 896.

NAME: T. M. AGE: 15 SEX: Male RACE: White

TISSUE Pnotl: 6. Right testis - surgery September 16th, l957. 6P. Recun·ent nodule, right scrotum, excised in February, 1958 .

CONTRIBUTOR: Seymour B. Silvel'CIIUI, M.D., et al, Mecorial Ho3pital, Phoenix, Arizona.

CLINICAL ABSTRACT:

HISTORY: There '~ere complaints of heaviness in the right scrotal area, Three to four weeks prior to entry, an orange si~d swelling was noticed in the right scrotum follol·7ing SlYimming and heavy lift ina. The chest x-ray was negative, Urinary gonadotropins were 90 international units/24 hours.

SURGERY: A right radical orchidectomy was performed on September 16, 1957, and a right retrope=itoneal lymph node distection on September 20tb,l957.

GROSS PATHOLOGY: The 7 em, partially encapsulated tumor mass extruded soft to rubbery, fin;;:" tan-white, slightly mucoid tissue through a breal< in the capsule. The cut surfaces in addition showed large areas of necrosis , old and recent hemorrhage and numerous blood-filled cysts, measuring up to 2 em. in diameter. Microscopic examination of the lymph nodes showed no indication of tumor,

FOL~~-UP: In February, 1958, the patient returned with a nodule in the right scrotum which was excised.

• '

;

REPORT ON THE

S 'l'UDY GROUP CASES

FOR

December, 1958

CASE NO. 1, ACCESSION NO . 8060, J ,D0 Kirshbaum, M.D,,Contributor.

LOS ANGELES: The vote was unanimous for malignant lymphoma, Hodgkin ' s sarcoma.

OAKLAND: Malignant lymphoma, 9 votes; small cell carcinoma, 3 votes,

SAN FRANCISCO: Undifferentiated small cell carcinoma of thyroid with metastasis, 3;

reticulum cell sarcoma, 2;· lymphoma, 1; lymphosarcoma of thyroid, Hodglcin's of liver and spleen, 1; reticulum cell sarcoma of thyroid, Hodgkin's of liver and spleen, 1; chronic thyroiditis, Hodgkin 's of liver and spleen, 2,

WEST LOS ANGELES : Lymphosarcoma of the thyroid, 8 votes; Hodgkin's disease of the thyroid

1 vote. Liver ani! spleen: Vote: Hodgkin's disease of liver and spleen, 9 votes. Cross-reference file: Reticulum cell sarcoma.

CENTRAL VALLEY: This was classed as an anaplastic mnall cell carcinoma by 2 and a

lymphoma by 6 members , "Those of us who favored the latter view realized that the distinction was often difficult and perhaps at times actually nebulous . Ho1·1ever, we felt that the diffuse itwolvement of the spleen was decidedly in favor of the lymphoma view, Some called it Hodg!~in 1 s and others histocytic (reticulum cell) sarcoma, but no one took such nome!lclatural niceties very seriously. It was suggested that the process may have started as, or from a Hashimoto's thyroiditis."

SAN DIEGO: Lymphoblastic sarcoma, 3. Metastatic reticulum cell sarcoma, 2. Undif·

ferentiated small cell carcinoma, 3 • of which one vote added metastatic,

FILE DIAGNOSIS: Cross-index:

810· 830 Lymphosarcoma, thyroid. 610•832 Hodgl~in' s sarcoma, thyroid, 610· 8076G Anaplastic small cell carcinoma, thyroid,

CASE NO. 2, ACCESSION NO. 9936, Frank R. Dutra, M.D., Contributor.

LOS ANGELES : The vote was unanimous for probable bronchial origin. The slides

studied showed lung tissue as part of the "rib" lesion,

OAKLAND· Primar.y adrenal

from lung., 6 votes. carcinoma, 6 votes : metastatic adet\ocarcinoma, probably

continued-

-2-Case No, 2, Accession No.9936-continued,

SAN FRANCISCO: Adenocarcinoma of unknown primary with metastasis, 11 votes.( PAS stain

was positive, many members thought that the lung could be the primary,)

tiES T LOS ANGELES: the vote: Mucinous adenocarcinoma, metastatic to both rib and adrenal

gland, 9 votes. COIII!Ient: 11\'le believe the patient had an occult primary carcinoma of the lung, stomach, or biliary system,"

CEtfTRAL VALLEY: Four members agreed with Dr. Dutra on adrenal primary, wh11e four held

that the lesions in the rib and both adrenals were alike metastatic and that the primary must be sought elsewhere.

SAN DIEGO: the question of the primary tumor, not determined,was discussed. Ketas•

tatic adenocarcinoma, 3 votes, the thrombo•phlebitis suggesting pancreas. the bluish staininS mucous, carcinoma of gastro-intestinal origin, ~ vo~es. No idea of origin, 1 vote. Origin of muco-epidermoid carcinoma - adrenals? Sali• vary gland? 3 votes,

FILE DIAGNOSIS:

Cross-index:

860·8091 I 229-8091 I

860·8091 F 229-8091 I

Adenocarcinoma, (PAS positive), metastatic to adrenal and ribs, Primary eite possible lung, stomach or biliary system. Primary adrenal carcinoma, with metastases to ribs.

CASE NO. 3, ACCESSION NO. 8252, 1'7. W. Hall, M.D., Contributor.

rps ANGELES : The vote was unanimous for aggressive villonodular synovitis.

OAKLAND; Localized nodular synovi'tia, unanimous.

SAN FRANCISCO: Infiltrating villonodular synovitis, 12 votes; invasive synovial granu•

loma, 1 vote. (Some of the members felt uneasy about the term synovitis and leaned more toward a synovioma.)

WE§T tps AN9BLES : the vote: Pigmented nodular tenosypovitis, 7 votes, Synovioma, 2 votes.

CENTRAL VALLEY: There were three votes for villonodular synovitis, one for benign syno­

vioma (no clarification of this concept was attempted), and two each for malignant synovioma and reticulum cell sarcoma.

SAN DIEGO: "All nine agreed that the man who classified the first growth as 'benign'

had adroitly escaped a 'trap', including here, a ~11 minority who hadn't, The 3F was agreed as having a more granulomatous loolt. Votes: Benign, (under several names) villonodular synovitis, 9 votes."

FILE DIAGNOSIS: 207.7-755 Villonodular synovitis, infiltrating. Cross•index: 096·8771F Synovial sarcoma.

-3-

CASB NO. 4. ACCIIIltlf 110. UU, W,V.Halt, Ll•• an' !.~.lleaJaai.J\. IC.D,, t .1Jtlckaea, M.D., Contri~vtora.

lP5 ANGELBS; the preUatnaq -.ote waa evenly 'iviclei ktveea anaplutic carcinoma

and ~nocytic leakemla, ( 5 and 5 ), A request vas made for more material, blood smears and bone marrow. • • •

~· t t • Unclifferentiatecl neoplasm probably1~yaph~, · lt 'votes, Neuroblaatoma,

1 vote,

SAH PM!i9ISCO: • • Undifferentiated carcinoma of nasopharynx with metastasis, 9 votea;

malignant tumor (neuroblastoma?), 1 vote; extramedullary soft tietua pleama­cytoma '~ith metastash, 1 vote.

WBST U)S AHGEU!Sj Left &ntt'\1111: Vote: Undifferentieted carcinoma of antrum, 7 votes,

Malignant lyaphoala of antrum, 2 votes. Adrenal gland: Vote: Malignant lymphoma, 8 votes. Undecided, 1 vote.

C!NT!W. VALL[l; This vas considered a reticul~ cell sarcoma by four and a lympho­

epithelioma by three, while a particularly astute and candid member conceded that he didn't know, Reference uas made to the discussion in Dr, Fisher's State Conference on possible origin of ''malignant lymphocytes" from epithe­li~. Here, as in NO. 1 the apparent diffuse splenic distribution appeared eomewbat in favor of lymphocytic-histiocytic rather than epithelial character.

SAN Dl!!GO: Dr. Meador saw a n~ber of thes e cases among Malayans in Guam, anaplas­

tic malignact growths starting in the nose. The vote: Anaplastic malignant t umor, 9. (Melanoma? 1; neuro-epithelial tumor? 1; from neural, as having more cytoplasm - reticulo sarcoma 7 3; lympho-epithelial tumor? 2.)

PILE DIAGNOSIS: 318-8191G Undifferentiated carcinoma of naaopba~. Cross-index: 318·830 Lymphoma, nasopharynx.

CASE NO• 5, ACCESSION NO. 9649, John J, Gilrane, M.D., Contributor.

LOS ANGJLBS: 'l'ha vote was unanimous for adenocarcinoma of colon with metaata1e1 to

ovaries.

OAISLANI?i Adenocarcinoma of ovary with metastasis to ovary, 10 votes. Adenocarci-

noma of ovary and adenocarcinoma of colon ( two primaries), 2 votes.

SAN JRANCISCO: Adenocarcinoma of colon and papillary cystadenocarcinoma of ovary, 5;

adenocarcinoma of colon with metastasis to the ovaries, 6.

WEST LOS ANGELES: The vote was unanimous

adenocarcittoma of the colon. for papillary adenocarcinoma of the ovary and

Primary in the colon with metastasis to the continuec!-

-4-

Case No. 5, Accession No.9649 - continued.

ovary, 5; Primary in the ovary with metastasis to the colon, no votes. Primary in both places, 4 votes. ( It ie admitted by the majority that one cannot be sure as to which was primary,)

CENTP.AL VALLEY: It was agreed that this was a primary carcinoma of the bowel with

ovarian metastasie.

SAN DIEG9: It was agreed that this waa the same tumor in both places - 9 votes.

Question of differentiation of the sucous by muci-carmine etain raised aa · suggesting the origin. The YOte: For t~ independent tumors, 3 ; papillary adenocarcinoma, ovarian origin, 3; intestinal origin, 3.

PILE DIAGNOSIS: 660-8091 Adenocarcinoma of colon with metastaeea to 788-8091 I-ovary.

Cross-index: Double primary: 788-8033F Papillary cystadenocarcinoma, ovaries. 660-8091 Adenocarcinoma, colon,

'b CASB NO. 6, ACCESSION NO, 973~ Seymour B. Silverman, M.D., et al,

Contributors. LOS AHCBLBS :

The vote was unanimous for teratocarcinoma. Recurrence ie simple embryo• nal carcinoma.

OAXI.t\ND: Teratocarcinoma with choriocarcinoma, unanimous,

SAN FRANCISCO: Malignant teratoma of testis, 7; embryonal cell carcinoma with teratoma­

tous component in the metastasis, 4.

WIST LOS ANQBLBS: The vote was unanimous for teratocarcinoma of the testicle,

CEN'lRAI, VALLEY: The vote was unanimous for a testicular teratocarcinoma. It was noted

that the scrotal recurrence showed better differentiation than the original lesion. Attention was called to the female pattern of the nuclear chromatin in the tumor. ( CF the recent paper in Science).

SAN DIBGO! The vote: Teratoma of testis with malignant metastasizing embryonal

epithelioma, 9 votes,

FILE DIAGNOSIS: Teratocarcinoma, testicle with choriocarcinoma, 755-882 p 755-880 p

Cross index: 775·8835F Embryonal cell carcinoma with teratocarci-noma, testicle.