242 BRIT. J. SURG., 1973,

examination of sections by strong polarized light, for the foreign bodies may be quite inconspicuous by ordinary light microscopy. Foreign bodies that are not in proximity to the cells comprising the granuloma should be ignored, for they may be derived from either the surgeon’s or the pathologist’s gloves whilst handling the specimen.

Lee, Collins, and Largen (1952) state that no matter how benign the powder may be and no matter how quickly absorbed, it is, for the duration of its presence in tissue, a foreign body. Furthermore, the longer the granules remain unabsorbed the more advanced the foreign-body reaction will be and the less chance there is that it will be reversible. When a complicating factor such as an infection is added to the foreign-body reaction of the tissues the process is exaggerated and the extent of permanent scar tissue is proportionately increased. The amount of the contaminant powder is another factor in the pathogenesis and, as would be expected, the larger the contamination the greater is the lesion. The variation in response is reflected in the clinical manifestation after contamination by starch powder. The time lapse may be between 2 weeks and 4 years (Cox, 1970) but most appear within a few weeks or months (Saxtn and Saxen, 1965). Mackey and Gibson (1948) describe florid granulomata developing within 2 weeks of implantation of talc, and Walker (1948) has shown that a siliceous granuloma can produce a firm peritoneal adhesion in 7 weeks. However, talc may also remain dormant in tissues and 45 years may pass before a lesion appears (Roberts, 1947). In the example reported here over I I years elapsed between the two operations within the scrotum. Neely and Davies (1971) consider that the condition is more common than is usually realized, particularly within the peritoneum. That starch powder is preferable to talc is borne out by Myllarniemi (1967), who found a foreign-body reaction in 61 per cent of patients after abdominal surgery, for which talc was responsible in 31 per cent and starch in I per cent of cases. Never- theless the comparative rarity of starch granulomata despite the wide use of glove powder and the possibilities of contamination suggests that the

Vol. 60, No. 3, MARCH

response is due to hypersensitivity or an allergic reaction. No such response was evident in the present case and no such experimental confirmation has been hitherto adduced (MacQuiddy and Tollman, 1948; Lee and others, 1952; Bates, 1965).

REFERENCES ANTOPOL, W. (1g33), Archs Path., 16, 326. BATES, B. (1965), Ann. intern. Med., 62, 335. BLAIR, C. R., and BLUMENTHAL, J. (1964)~ N.Y. St . 3. BUTTERFIELD, W. C. (1970), Conn. Med., 34, 180. COX, K. R. (1g70), Br. 3. Surg., 57, 650. GERMAN, W. M. (I943), Surgery Gynec. Obstet., 76, 501. HYDEN, W. H., and MCCLELLAN, J. T. (~gsg), 3 . Am.

LEE, C. M., COLLINS, W. T., and LARGEN, T. L. (1952)~

-- and LEHMAN, E. P. (1947), Ibid., 84, 689. MCADAMS, C. B. (1956), Surgery, S t Louis, 39, 329. MACKEY, W. A., and GIBSON, J. B. (1948), Br. med.3. , I,

1077. MCNAUGHT, G. H. D. (1964), Br. 3 . Surg., 51, 845. MACQUIDDY, E. L., and TOLLMAN, J. P. (1948), Surgery,

S t Louis, 23, 786. MORGAN, A. D. (1964), in The Pathology of Testicular

Tumours (ed. COLLINS, D. H., and PUGH, R. C. B.), p. 95. Edinburgh: Livingstone.

MYERS, R. N., DEAVER, J. M., and BROWN, C. E. (1960), Ann. Surg., 151, 106.

MYLLARNIEMI, H. (1967)~ Acta chir. scand., 377, suppl., I. NEELY, J., and DAVIES, J. D. (1g71), Br. med. 3.) 3, 625. PHILLIPS, D. E. H. (1961), Br. 3. Urol., 33,448. ROBERTS, G. B. S . (1g47), Br. 3. Surg., 34, 417. RUSSELL, T. R., ROQUE, F. E., and MILLER, F. A. (1966),

SAXEN, L., and SAXEN, E. (1969, Acta path. microbiol.

SHATTOCK, S . G. (1917)~ Proc. R . SOC. Med., 10, 6. SHOULDICE, E. E., and MARTIN, C. J. (195g), Can. med.

TAFT, D. A., LASERSOHN, J. T., and HILL, L. D. (I970),

WALKER, W. (1948), Br. med. 3 . , I, 1079. WEED, L. A., and GROVES, J. L. (I942), Surgery Gynec.

WOLMAN, M. (1970), in Pathology Annual (ed. SOMMERS,

Med., 64, 1202.

med. Ass., 170, 1048.

Surgery Gynec. Obstet., 95, 725.

Archs Surg., Chicago, 93, 245.

scand., 64, 55 .

Ass.J., 81, 636.

A m . 3 . Surg., 120, 231.

Obstet., 75, 661.

S . C.), p. 381. London: Butterworths.

NEURILEMMOMA PRESENTING AS A LUMP IN THE BREAST BY RICHARD COLLINS AND GILLIAN GAU WYCOMBE GENERAL HOSPITAL, HIGH WYCOMBE, BUCKINGHAMSHIRE

As far as is known a neurilemmoma growing in the breast tissue has not previously been reported. Such a case is described here.

CASE REPORT The patient was a 43-year-old housewife and mother

of 4 children. One child had been breast-fed for a month, the second child had not been breast-fed because a breast abscess had developed, and after the births of the other t children breast-feeding had been suppressed.

Nine years prior to admission the patient had been on a contraceptive pill for I$ years. In 1965 she had had a hysterotomy for a termination of pregnancy. She also had curettement of the uterus and dilatation and

cauterization of the cervix in 1966 for a cervicalerosion. She had had a variety of complaints recently including de- pression and, 6 months prior to admission, a mycoplasma pneumonia.

The patient presented with a lump in the right breast which she had noticed for 14 weeks whilst she was having a period. It was not tender and the patient thought that it might have become larger during the time that she had waited for an out-patient appointment.

On examination she had a firm lump, t x I em., of rubbery consistency and regular outline in the upper outer quadrant of the right breast. This was mobile and not tender. There were no axillary or supraclavicular nodes palpable, no stigmata of neurofibromatosis, and

SYMES AND EADIE: HORSESHOE

no other abnormal physical signs. She had not noticed any discharge from the nipple. Clinically, it was con- sidered that the lesion was a fibro-adenoma of the breast and that it should be removed.

FIG. 1.-Characteristic nuclear palisading in Antoni A areas. H. and E. ( x 75.)

OPERATION.-At operation a freely mobile lump was removed from deep in the breast. It did not have the appearances of a fibro-adenoma in that it seemed myxoma- tous and there was an area of yellow material a t one end that looked like hard, dense fat. This was subjected to a frozen section, the report of which was inconclusive. However, it was felt that there were no grounds for advocating a mastectomy until the paraffin section had been seen. The wound was closed with silk sutures and the patient returned to the ward. Subsequently the wound healed satisfactorily and the patient was dis- charged a few days later. Postoperatively she has remained well.

KIDNEY AND AORTIC ANEURYSM 243

HISTOLOGY.-Paraffin sections of the tumour showed a typical neurilemmoma. Both the main histological features of Antoni A areas (highly cellular with a dark- staining cytoplasm) and Antoni B areas (pale cells with an irregular outline lying in a watery matrix) were present. Within the Antoni A areas there were groups of cells showing the characteristic palisaded nuclei (Fig. I) .

DISCUSSION Solitary neurilemmomas or Schwannomas may

arise from any nerve that has a sheath. They are thought to be tumours of the Schwann cells which comprise the nerve-sheath, although there has been some attempt to cast doubt upon this theory (Penfield,

Neurilemmomas may be intracranial or peripheral. T h e commonest form of intracranial neurilemmoma is the acoustic neuroma. Peripherally the commonest sites are on the flexor aspect of the principal nerves of the limbs, in the posterior mediastinurn, and in the stomach (Stout, 1935). However, although various sites have been described we can find no evidence of one presenting as a lump i n breast. In several series (Willis, 1967) it has been noted that whatever the site females are more frequently affected than males.

The tumour itself is not locally invasive and, depending upon the site, it should be possible to enucleate it completely without damaging the under- lying nerve. Local recurrence only occurs if enuclea- tion has not been complete.

Acknowledgements.-Our thanks are due to Mr. Peter Lord and Dr. David Spencer for allowing us to report on this case, to Professor Noel F. Gowing for his second opinion on these sections, and to Mr. Martin Casling for the photography.

1932).

REFERENCES PENFIELD, W. (1932), Cytology aizd Cellular Pathology of

the Nervous System, vol. 3, p. 953. London: Hafner. STOUT, A. P. (1935)~ Am. J. Cancer, 24, 750. WILLIS, R. A. (1967), The Pathology of Tumours, 4th ed.,

pp. 54, 843. London: Butterworths.

HORSESHOE KIDNEY AND ABDOMINAL AORTIC ANEURYSM BY J. M. SYMES AND D. G. EADIE

THE LONDON HOSPITAL

SUMMARY A case of horseshoe kidney and an abdominal

aortic aneurysm is presented. T h e 32 previously described cases are reviewed and the diagnosis and management are discussed. T h e major factors influ- encing the operative approach to an aortic aneurysm associated with a horseshoe kidney concern the site of origin of the renal arteries, their number, and the portion of the kidney which each supplies.

THE association between a horseshoe kidney and a n abdominal aortic aneurysm has previously been reported and 32 cases are documented in the world

literature. A further case is described here and the previous 32 cases are reviewed.

CASE REPORT Mr. J. S., a 65-year-old man, presented with a 4-

month history of aching midlumbar backache and abdominal pulsation. On examination he was found to be normotensive and to have a large abdominal aortic aneurysm.

INVESTIGATIONS.-A radiograph of the abdomen con- firmed calcification in the abdominal aneurysm. An intravenous pyelogram (Fig. I) showed calcification in the right kidney and malrotation of both sets of calices, suggestive of a horseshoe kidney. The blood-urea was 33 mg. per cent.