Al'O 4)

i'ATHOIOGY ------- .... - .., IllAR --- ·---9 u"l'oh J.9:>5, l')JO houx·.? ('/::;10 p. :n.)

6th !"loo:. , 'a tholog;r C mi' • r.oe RoC!!

(l'o\.o: Tw.. I.s.urcu v. 1\cl .. 1'···'1 y 9.1'.t nd tl.1is oeesion,)

.f sf/ lt:11.~ k.L:.l.

/ Slido .Ill Pro~rnted by Que.,'

v:tr."'.J:a ht:d a :Wrd.on 'l.n the vac;:u.n,

J

·na ·;c.:~. Ws biop..«y o a r fri&hlc, wlD u ~;ntira spec u J tm:: ' f' r: b p~ •

0 181

A~1\ Qk~ .,...J.de 3 Pr lllit-cd b;

'lllia in a h!opsy o.r: a flliOltcy ala atod, £ rn lesion on in fr the sc.~lp.

P .'.l\ rno 1o :

-- __ ._.,.__ ------2 & 4 ft'asentc.d by c. •s Hospital.

:u: io'DwY ot a les:l on found on •Jbya,.r .... l ezu:!LOO tit n 1n t l'uttocl o.t: ~~- Groa J.y t~:::e = a c:Lrcunmcribed J.aoion t2 oo1J;y of ~l•ltaus !II.:.$Cle1 •liSur:l.ng I, :t X 2 au. ln.tie":i.Dite Jll'lll{i so mad ~o ox'lZltt ini;o &lll'l·o•onding mwcJ , It 11.:w lll\tooid and ;;thl. ~o Qn cu ::Jeotion.

Ilia!J!O is:

J Slide 115 Presented by (,)~can ' s Hoapi 'tal.

oupraclav:i c:tllar nodule aa felt. nd on 01ll' about 1.5 em. in ',r oter · s f01md.

t mru:cL:,

er_,..., vir ---' is pa1.c!lt i" a 41-:J&::lr olr! ·"2p; ~ .. ,., ._;le '-' r.1.; ~.; ' i,tc' t:'l

Plll:ill

Iilboratory: 'l"nrc:~ :;;mtw:t concent:rtttos r ~ u.w :i:or #. J t :o '1'11 :::1 Cl.!lturc

C.:-'>.t. :c ---t}3l2SB l'rJaerrt ' l by Str.Iltb Cli'l.ic.

~ ]J-ycm- cld pn•t-t!E.1~a:J.ian [';!.r1. l!aticA n lm:Ip in 1 r :..~n brc t r.esks bof cro oolWul tin~ a phys:L~ on t o Lr,J..Ii.M ,., tu:.i • aw Jj • 3 dcn.o, £oll0'73d by Gi"mle 8 lit~ ic." ir

CAS .. xn --3443-54 Pl·csmrt.ed by St.. I'rll.neis f.ospital.

l:al"l, age. lB. Aa;imptOJntio eyatie lesio.'la or Wt l.oT.er t:).hia anri bU•torally o.t: lower fe!lll.ll' . Blood culciwu v;ea 11.4 m~1 ellr&\l.in'1 phosphai;aee 2 ,'J BodD.nsky Ullitl!l (our nOl'Il.:J.lls 2 to 4 nntta), and ! p'!,ophoz·ua af 4 • .) ~. .sac!: bono cyst 'l'hlt: tillod "ith 110lid• 1 ubtar,y J l:u•own tinsuo. 'lhcre \i'Jl'EI no care au lai t opots.

--------·----------------c:\51: nn

#J2(1)9 T'res.sntod by l'ripler ./iJ:rJry Hosp:i 'l:l.ll •

.34-:l"'IIX' old whits £cmue ubo t;i.vt'R an unral:tabla history, '"t. is inrnrre;! that 11 goiter T.ac disenoood in 1944. ~ wc.s troatcd t the til:e by a course of tablDts (ttzyraid ?) and s-..:.bstquont:cy by th'aa ~ '•i:l.tio::ll sit!Uer courses, tbs longect. beint; tar 6 "aeks .

3m 1'£\d 't>allll told rgpoatedl;y tho. t tho goi tor ehould bo :'£ll!OVCd: h1.t

~LlJ06 Prr.lle:tl.td by ~la v;ho :; "Dntllr pt•aviO'.lS~ had ll eubt"t 't ..1Qro1.•' nt«zy :!."or a dl.f.!U!lo toxi.c goi ;;.;.1• • confiru:xl his tologicn.J • .I.;y. Sil. ~o hnt o:1nc llho ~>lo had m~tr.,:rrh:l!J;i.ll. ,, :J!tC was par. 'o\'t:.::Q.

Tnio 1a act a partl.culal·~· {;Ood o.'03 but is pre:.~ant&d p:-5 U'1ly t.o ::rovclco GJ.l£ diacu.oaion ns 1.o ·t.aa dll'!Ol•ent.i.nt.ion of atypiua l~;c:rpl•si-"l frou;. ~·ci.non!a of tho endOIGltdum.

r:, --yc.:u' old nhi te fomal.o 'l'lith a 2 rontlw 1 hiD ::.Ory of cpi[Jurtric 4J.' .... • wm. ~. A lJl'O:WJ.oric ulcar'-t.:1~ losion was coni'1.l'IlC::l 'to'

J •oy .r 11Di a .,.ub+JOtal gastrcctor.w t.'a::J por!"ornod.

---------------------------------------------------------------~.1-:!!.

11594 Proso•1~cl. by Tl."ip:Wr .oll'!llY Hospital.

35-ycar c•ld llhito fQ:Ial~ r.bo has h!ld an ocs;cmtoWJ lDsion or tho le£t m rPh ~ce 1947. 1hio IreD rrev.IJJW5l;t biopoied at a forei•)l t·as!l:l.ul, l.'ut tho results o!' this e::ani.Mtion 1\l'Cl not knmm. At. 'lho r·rosrn. i:irJo '.t i!:: a ecaJ,y ulcerated lesion.

1'11 o sl.id6 ;.s not included £or ruw pru.otinttllll' d.iscussion lntli :I.G i'clt h• :rop:;;•_:;ani. E. i'ail.'~! oliBl'llOteril'tio piotUl'O o~ the lesion 1. t roproo , .. ilfJ.

r 1l

: c~:lo ..

CASl~. X'lTil -·---ll56'• Pre:;cnt

fLJ:: C/l.S):; IV, !tiL\¥~~ rmS-54. ~~·t Ol 15 DLC. 19~.:.

(Conrtes.y of S~al!b Glin1c)

"·ic"i"ilruJ. poo~;.,n propo 'ed by ·;,9 t f:f' ior

t! ' l'oti'oper~ tono.:l tumor 1n tJl9 once n:f nobert 'ICO.nl;ko, ynur "' ' 'I'

n~·-')4, r~~ ~,::esl'i.ol'l f-t!?U.1. ) 'lbe j'Jli.ty favor 'ik"~r -:-.t -rr':

IC.'ll.l'!IWm or 'lcli.~.m'~ ca. Ha~nno ;::rteyto!t.l t:ull al.•o c •

Jl."'ll10/'l"• VI~··PII II.MO:lt:WJ

II.Y, S a.¢11 1i.l.o.ll'r A~U 9wn". o,p " ""'~'"n·• .,.,,...., ... ,.

~o~.o.. s.., M.o .

THE QUEEN'S HOSPITAL HONOLULU 9 . HAWAII

R()K ~ M· D l W tVUI. It, H. H . 8 OtiiCC'TC.II Or 1(11-II".NO" 5CIIIVIC:t /\NO 101"--'"IODI. OP ,. .. ,..,,. .. ' ~ . c .. ~ .. ton-~" L0\11• D , a vu.oo, M . o , tiJJI~ClOII 01" I! .. D!OI.OGY ,.o ..

•,

Dr. Ackerman - (2)

Case 4 (Slide V) This lesion was found in the superior mediastinum and was cystic measuring 10 x 6 x 3 em. and weighing 103 gms. It was ovoM in shape. The wall was smooth and measured l em. in thick-ness . Lobulation was noted as was a small pedicle·. The contained f l t!id was seropurulent • ')to f......._· .. , .,..__ / . . ' ~ ~ .c.-- t. t

An interesting facet of the history was the fact that the cyst increased in size during the menses~ .4.., -

7 }--

CJ\SE 1 - This is a malignant tumor involvif18 the vagina, which .forms

acini. It certainly has none of the characteristics or a squamous

carcinoma end would have to be considered as a highly maligoa.nt

adenocarci:l!o:m.. The presence ot clear cells in the specilnen :ne.kes it

illlperative to make sure that this is not metastatic from the kidney.

He have seen metastatic tumor ft'Oln the kidney in the vagina and vulva

and in many bizarre places such as true cord of larynx, the bronchus

tvice, skin of the ear, end upper lip. It would be very important to

have differential stains, fat,, epithelial mucin . I.f' this section

contains epithelial mucin, it is most certainly mot from the kidney.

We removed the cover slip and stained the slide for epithelial mucin,

and 5::IBl.l n.~unts of mucin are present. This is not the usual adena-~

carcinoma of the cervix. Neithor is it the usual adenocarcinoma of

the endometrium. A high percentage of adenocarcinomas of t~~ endo-

metrium do not secrete mucin. There is a possibility, of course,

that this is primary arisifl8 in the vagir.a, but this is a very rare

lesion . There is another and possibly better possibility thut this

lesion is metastatic from some source such as the ovary.

Microscopic diagnosis : Vagina - Adenocarcinoma (Prim:!.ry source uncertain)

CASE 2 -

sebaceous ds vith evidence of slight chronic in!J.anmlation in the

subcutaneous tissue. There is tumor present which is epithelial in

nature and which is reaativoly mdirterentiated. This tumor is graving

in relation to 1:meat glands, and it vould be very tempti ng to call this

a sveat gland cancer. This is, or course, an \Ulusual ~ocation, and the

0

·-

pattern

- .) -CASE 5 - This su~raclav1cular node shows replacement by a papillary

tumor which is well di:f.ferentia-ted and shows areas of calcification with

.emall psammomn bodies . Tbere is also calci.fication of the connective

tissue capsule. I would have to assume that this is metastatic

papUJ.acy carcinoma, probably from the thyroid. It i s somewhat cystic.

This is per.fect~y compatible . Even it there is no evidence of tumor

in the thyroid, I would consider this as a.'1 indication !'or total

thyroidectonzy- . I am quite certain the.t a :Primary tumor would be :found

there, and it is not at all unusual for this tumor to hs.ve multiple

foci of origin, "hich is the reason for the total tJ:zyroidectolT\)' . let

us suppose the.t t hyroidectonzy- was not done . I would not be surprised if

several years elapsed, perha~s even more than five without signs of

tumor in the thyroid. This would not indicate that cancer '\IRS not

present in the t hyroid. The duration of disease in t his type of tumor

can be extremely long. We knov of one patient who has been liVing

w1 th disease \fell over 20 years .

Microscgpic Diagnosis : Izymph node , supraclav1cul.o.r - ~!etastatic papillary carcinoma.

(Primary probably thyroid)

fYO""'"'\ . ~~ CASE 6 This is a rmmarkable example of carcinoma in situ lining a

bronchiectatic cavity. These changes are very definite, show epihhelial

alterations throughout the entire thicmness of the epi thelium. There

are some nests of cells extending deeply into the tissue. But I

expect that these extensions represent neoplastic processes invol ving

mucous glands. It ·•ould be possibl e to demonstrate these by sections

at various levels, stains to demonstrate basement membrane and

epithelialli!Ucin stains .

- 4 -

We have seen carcinoma in situ of the bronchus on biopsy on

several occasions, but it has always been in association with insasive

~arcinoma . Willi ams reported extensive changes in the bronchial epi-

thelium associated with multiple invasive carcinomas . We have seen

carcinoma in situ extend for long dis!lances along the bronchus. rr

carcinoma in situ is present at the line of resection, this is an

ominous finding, and all such patients have died following pne~ectocy.

Microsc op ic Diagnosis : Lung - Extensive carcinoma in situ with possibl e i nvasion

- Bronchiectasis

References : Black, H. and Ackerman, L. V. , The importance of epidermoid carcinowa in situ in the histogenesis of carcinoma of the lung, Ann. Sirg. 136: 44-55, 1952.

CASE 7

Williams, ~!.J . , Extensive carcinoma in situ in the bronchial mucosa a ssociated with two invasive bronchogenic carcinomas, Cs.ncer 5 :74o-7lf7, 1952 .

This is a malignant t\llllor involving t he br onchus .

However, it is ap~·ently superficial, and in only one occasion has

it dipped between the bronchial. cartilages. Portions of two nodes are ....,;

tree from evidence ot tumor. This has a Jl9¢1nn o1' a carcinoma. I

say that because of the fact that it io well set off from the back-

ground of lymphoid s·~roma . On its margin there are areas of palisading.

The fact that it is located mainly ~thin tbe lumen would malte the :f'"" / '

outlook favorable, in spite ot the relatively poor differentiation of

the neo_plasm. I have seen bronchial adenoma carcincsarcoma d:o this I I

and a well differentiated squamous carcinoma.

Microsc op i c Diagnosis : Lung, bronchus - Carcinoma

CASE8 'l'"ois is a granulomatous process with numerous giant cells,

and these giant cells often surround brown organisms which ere round

with central bodies. This slide ws reviewed by Dr . Morris MoOre, our

- 5 -

expert :l.n fungus diseases. He came to the conclL

- 6 -

but this encapsulation proved false . Tumor giant cel l s are numerous,

and in many areas there are signet ring cells . Fib:-osarcO:Ms usually

do not have giant cells . The most COillllon differential diagnosi s is

bet'\\'!! en this and a rhabdomyosarcoma . Rhabdomyosarcomas may have tumor

giant cells, but they also have strap-like extensions of the cytopla&:n

'ihich are eosinophil ic staining . Cross stratifications unfort unately

are not present in the more undifferentiated tumor .

In this instance the decisi on as to further therapy is a difficult

one. This decision will involve the possi b i lity of re-excision,

disarticulation or even bemipelvec~.

f.!icroscopic Diagnosi3 : Soft tissue, thigh - Liposarcoma

Reference : .Lieberman, z. and Ackerman, L. V. : Principles in V.anagement of Sott Tissue Sarcomas, Surgery 35 : 350-365, 1954.

CASE ll There is adenom&tous proliferation of Brunner's ~~ds

with oome evidence of chronic in.f'lamma.tion . There are some fairly

large ducts extending down into the glands . We do not believe this

is a malignant process . This is highly rare in our experience, and we

have never seen a lesion of this type . Thi s is an extremely unusual

lesion. There is very little information in tbe literature. There

have been a few apparently me.lignant tumors arising .f'rom :Brunner's glands,

but we have never seen one . Robertson has illustrated en adenoma of

:S.."Wlller' s glands. It is really a question wether to call this lesion

focal nodular hyperplasia or true tumor. ~1e certainly do not know

their function . There are acinotubular glands largely located in the

Subi!IOCOSS.

Microscopic Diagnosis : SmaJ.l intestine, duodenum - Adenoma:tows process of Brunner's glands

Reference : Robertson, H. E. , The Pathology of Brunner's Glands, Arch. Path. 31 :112-130, 1941 .

- 7 -

CASE 12 - This is a benign l e sion. Differential diagnosis lies

between metapcyseal fi·orous defect , gia-'lt cell t umor, f ibrous dysplasia. ,

and hyperparathyroidism. The lack of cystic cballges without eVidence

of brown tumors , exuberant bone destruction and bone production , but

most important the presence of a normal alkaline phosphatase rules

out hy:perpara.t byroidism. This is in t he 'Rang l ocation for a giant

cell t=or, although this is a lesion often confused with it. In

fibrous dysplasia there is usually the thin, curved, new bone spicules

separated by fibrous t i ssue. This lesion falls into t he category of

metaphysea l f ibr ous defect , and t hese l esions may be mult ipl e . The

radiographic appearance is usually diagnostic .

Microscopic Diagnosis+ Bone - hrul t1pl e metaphyseal defects

References: Hatcher, C.B. , The_Pathogenesis of Localized

CASE 13

Fibrous Lesions in the Metaphyses of Long Bones, /Inn. Surg. 122:1016-1030, 19~5 .

Jaffe, B.L. and Lichtenstein, L . , Non- osteogenic Fibroma of Bone, Am . J . Path. 63 :205-221, 19~2 .

There is a poorly defined nodule in the thyroid which is

probably the soft nodule descri bed. This shows follicl es of various

s izes . There a re small zones which demonstrate eVidence of hyperplasia

with tall columnar epithelium, pale stained and vacuolated colloid.

There are smal l f ocal a r eas of calcification of t he stroma. In some

areas the indiVidual nuclei sho-w tremendous variation. We do not

feel thi s is evidence of malignant change . We have seen such nuclear

alterations before, particularly in patients vith "burnt out hyper-

thyroidism." The remaining thyroid is not remarkable .

'7?7

Microscopic Diagnosis: Thyroid - Adenanatous with focal hyperplasia

- 8 -

CASE: 14 - ~!.."Lny .l:'ra@lle.nto of endometrium show rather active stroma

with somewhat tortuous £)ends . However, there are focal areas in which

there are aberrations of the gJ.ends, of glands within gJnnds, and I

think that we have to desisnate this as early adenocarcinoma. This is

a type of case which Hertig has described in tre younger age group,

which may have disturbances in menstrual function, and usually if they

are married, so not have children. I think that in -.;his particular

case, intracavity radiation should be given followed by at least

hysterectomy.

Microscopic Diagnosis : Uterus, en~trium - Adenocarcinoma

Re;t·erences : Hertig, A. T. , Endometrial carcinoma. 2:946-956, 1949.

and Sommers, S . C.: Genesis of I. Study of Prior Biopsies, Cancer

CAEE 15

Hertig, A. T. , Sorrmers, S . C. t and Bengl.off, H. : Genesis of Endometrial Carcinoma. III. Carcinoma in Situ, Cancer 2:9611-971, 1949.

This section shows superficial alterations in the epitheliua

of the mucosa of the stomach which have to be designated as carcinoma.

ihese changes are confi ned to the mucose and do not extend through the

muscularis mucosa. Accompanying these alterations there is some

evidence of acute inflammation on the surface with some fibrosis between

the glands. In the submucosa there is increased thickness With

fibrosis and chronic inl:'lammation. There is also some incx·eased

fibrosis between the muscle bundles .

This is a iesion which bas been desigoated as superficial

spreading t ype and has been well describdd by the French and in this

country by Mallory and Stout . These lesions may have a '\/ide extent

on the surface, as much as 54 square ems . The incidence of l ymph node

- 9 -

metas tases is lov, and therefore the cure rate is high. It DIUBt be

remembered, however, that multiple foci of origin may occur .

Microscopic Diagnosis : Stomach - Carcinoma, superficial spreading type

References : Gol den, R., and Stout, A.P . , Superticiel Spreadins Carcinoma of the Stomach, Am. J . Roent genol. 59:157-167, 1948.

Gutmann, R. A. , Bertrand, I., and Perist1any, Th.J. , Le cancer de l ' estoma.c au debut, Paris, 1939, Gaston Doin & Cie .

t·:a.J.lory, T. B. , Carcinoma in Sit u of t he Stomach and Its Bearing on the Histogenesis of lo!aliinant Ulcers, Arch. Path. 30:348-362, 1940 .

CASE 16: - This i s classic Paget 's disease or t he breast wit h tu."!lor

cells involving overlying epit helium and the underlying duc t s. I

cannot see any evidence or extension outside the ducts . The se tumors

arise from the ducts and secondarily involve the nipple .

It ie not too unustml for them t o be of long duration and for a

the process to involve/wide area of the ski n surface. It starts,

hovever, on the nippl e and secondarily u

- 10 -

case was seen bl Dr. Manhold1 ~rho is the pathologiat to ot\r Dental

School, and he thought that this was a tumor of odontogenic origin,

possibly cementoma. He also brought up the possibility of ossifying or

calcific degeneTative fibroma .

Microscopic Diagnosis : Bone, nandible - Odontoma

Reference : Thoma, ICII. and Goldman, H.M. , Odontogenic Tumors, Am. J. Path. 22: 433-471, 1946 .