Herbert B. Taylor

Relationship of histologic features to behavior of cystosarcoma phyllodes. Analysis of ninety-four cases

The clinical and pathologic findings in 94 patients with cystosarcoma phyllodes were studied to determine which pathologic characteristics were related to clinical behavior. The neoplasm recurred in 28 patients and 15 patients (17%) died of metastatic cystosarcoma. Most recurrences occurred within 2 years of initial surgery and all patients who died of cystosarcoma did so within 6 years. No tumor less than 4 cm in diameter or having fewer than 3 mitotic figures per 10 hpf in the areas of greatest mitotic activity proved fatal. Other microscopic features associated with a low risk of recurrence or of death were pushing margins (one death in 39 examples) and minimal cytologic atypism of the stromal cells (two deaths in 30 examples). No one feature was wholly reliable and a clearcut separation of benign from malignant tumors could not be made. Although axillary lymph nodes were enlarged in 17% of patients, metastasis to them occurred in not more than three instances (one histologically proved) and therefore radical mastectomy or routine axillary lymph node dissection is not worthwhile. Wide local excision for small cystosarcomas and simple mastectomy for larger ones is recommended. In addition, low axillary dissection should be considered in patients having clinically enlarged axillary lymph nodes and tumors larger than 4 cm if there is marked atypism of stromal cells or high mitotic activity, as determined by microscopic evaluation of the cystosarcoma.

Mesenchymal tumors of the uterus: III. A clinical and pathologic study of 31 carcinosarcomas

The clinical and pathologic findings of 31 patients with uterine carcinosarcoma are presented. Carcinosarcomas arose within the endometrium and all but 2 invaded the myometrium and lymphatic spaces. Tumor had spread beyond the uterus in 12 (39%) of patients at the time of initial therapy. None of 8 patients (26%) who were free of cancer at last contact had extra‐uterine extension or metastasis. Because the patients with carcinosarcoma had a significantly better survival rate than did a similar group with mixed mesodermal tumors, the 2 types of neoplasms should be separated. The authors believe that carcinosarcomas arise both from multipotent neoplastic cells that have the capacity to form both epithelium and stroma and from multiple neoplastic cell types having fixed potencies. Origin from embryonal rests, primitive analagen, or collision tumors is rejected. Because the distribution of metastatic lesions of uterine carcinosarcomas is similar to that of endometrial carcinomas, surgical management should be similar. It is not clear whether irradiation has any value as treatment.

Prognosis of granulosa-theca tumors of the ovary

The clinical and pathologic findings of 203 patients with granulosa‐theca tumors were analyzed to determine the features related to subsequent behavior of the tumor. The neoplasms were divided into three groups—granulosa tumors, mixed granulosa‐theca tumors and thecomas. The actuarial survival rates of patients with granulosa tumors and mixed granulosa‐theca tumors were nearly identical—both 97% at 5 years and 93% at 10 years. Only one of the 106 patients with a thecoma died of tumor, the other lesions being clinically and histologically benign. Capsular invasion and lymphatic invasion by the neoplasm were features associated with persistence of the tumor but the type of treatment, the degree of cellular atypism and mitotic activity were not. Unilateral oophorectomy is adequate therapy for granulosa‐theca tumors confined to the ovary if biopsy and frozen‐section examination are done on any suspicious lesion of the opposite ovary or other pelvic structure.

Carcinosarcomas and mixed mesodermal tumors of the ovary

Mixed epithelial and mesenchymal tumors (carcinosarcomas and mixed mesodermal tumors) are well‐recognized entities in the uterus. It is not widely acknowledged, however, that histologically identical tumors also occur in the ovary, as less than 17 well‐documented examples have been reported to date. A clinical and pathologic study of 13 carcinosarcomas and 14 mixed mesodermal tumors of the ovary in the files of this Institute revealed that the clinical profile of patients with either tumor was similar. Typically, women were postmenopausal and nulliparous. An enlarging abdomen with a mass present for about 5 months was the most common mode of presentation. Grossly, the 2 types of tumors were usually indistinguishable, although by definition the mixed mesodermal tumors contained neoplastc heterologous elements (bone, cartilage, and striated muscle) in addition to carcinosarcomatous foci. The major difference between the 2 groups was in survival. The median survival for patients with mixed mesodermal tumors was 6 months, whereas it was 12 months in women with carinosarcoma. These findings agree with the survival difference noted by Norris and Taylor (1966) for the same neoplasm in the uterus. The differential diagnosis of carcinosarcomas and mixed mesodermal tumors is considered, with an emphasis on the differentiation from malignant teratomas (teratocarcinoma).

Polyps of the vagina. A benign lesion resembling sarcoma botryoides

This clinical and pathologic study of 24 vaginal polyps, 22 from adults and 2 from infants, was prompted by the need for recognition of a benign polypoid vaginal lesion which must be distinguished from sarcoma botryoides, rhabdomyosarcoma and mixed mesodermal tumor. Twelve of the 22 polyps from adults contained atypical cells within the stroma. Five of these patients were pregnant when the polyp was discovered. Follow‐up showed that the polyps are benign and adequately treated by local excision. The polyps from the 2 newborn infants were present at birth and were characterized by diffuse edema but contained no atypical stromal cells. One of the polyps regressed after biopsy. The other was locally excised and did not recur. Maternal hormones are thought to induce the intra‐uterine development of the polyps in infants. The criteria for distinguishing vaginal polyps from sarcoma botryoides, rhabdomyosarcoma and mixed mesodermal tumor are discussed.

Sarcomas and related mesenchymal tumors of the breast.

The clinical and pathologic findings in 32 patients with mesenchymal neoplasms of the breast were analyzed to determine which pathologic features were related to clinical behavior. The neoplasms were similar to mesenchymal tumors elsewhere in the body except that heterologous differentiation to form bone, cartilage, muscle and fat was surprisingly frequent. Recurrent lesions occurred in 12 patients, all within 14 months of initial therapy, and eight patients died of tumor, all within 5 years. Pathologic features associated with a low risk of recurrence or of death were a pushing margin (one recurrence, no deaths) and minimal atypism of the tumor cells. The degree of mitotic activity correlated less clearly with behavior but it was apparent that any tumor with five or more mitotic figures per 10 high‐power fields was capable of metastasis. Such features of the tumor as its size, its contour and the degree of its cellular atypism and mitotic activity should be given in future reports so that the reader can evaluate the potential of the neoplasm for himself.

Carcinoma of the male breast

Men with mammary carcinoma have a worse prognosis than do women, even after noncancer deaths are excluded. This can be explained partly on the basis of the high proportion of lesions that lie beneath the nipple area (78%), as centrally located lesions have a greater incidence of metastasis to internal mammary lymph nodes with its consequent adverse effect on patient survival. The central location and the absence of significant encompassing breast tissue also allow small mammary cancers of men to involve the pectoral fascia and the dermal and subareolar lymphatic channels simultaneously. On the basis of size, smaller mammary cancers had only a slightly greater frequency of axillary metastasis in men than women but had considerably greater lethality, presumably because of higher frequency of internal mammary lymph node metastasis.

ENDOMETRIAL HYPERPLASIA IN YOUNG WOMEN

Findings in a long-term follow-up study of 97 young women with endometrial hyperplasia are presented. In 24 patients (25%), the endometrial hyperplasia was associated with sclero-cystic ovaries consistent with the so-called Stein-Leventhal syndrome. Fertility in all of these patients was low; only 26 (27%) conceived in the years after endometrial hyperplasia was diagnosed, in spite of the desire and efforts to conceive. Only 20 patients (21%) carried their pregnancy to term. In 14 patients (14%), the lesion progressed to adenocarcinoma 1 to 14 years after the initial diagnosis of endometrial hyperplasia. Thirty-seven patients (38%) continued to have menstrual irregularities from 1 to 30 years after the diagnosis. Forty patients (41%) had a hysterectomy by the sixteenth year after the diagnosis. Outlined is a planned, aggressive, but flexible method of management that would promote a high conception rate and less chance for the endometrial hyperplasia to progress to adenocarcinoma.

Benign nonchromaffin paragangliomas of the duodenum

A series of nine tumors arising in the second portion of the duodenum has been presented. These tumors usually occurred in the fifth and sixth decades and clinically simulated peptic ulcer rather closely. Most of them were polypoid lesions not over 2.0 cm in diameter and were usually demonstrated on x-ray examination of the upper digestive tract. Histologic study invariably showed two elements to be present: one, a spindle cell component similar to the spindle cell portion of ganglioneuromas or neurofibromas; the second, and most often dominant element, nests of epithelioid cells indistinguishable from the Zellballen of nonchromaffin paragangliomas in more typical locations. Modified Bodian stains demonstrated a large number of neurites in the tumors and argyrophilia of many of the epithelioid cells similar to the findings reported in carotid body tumors and other paragangliomas. The histogenesis is considered, and our reasons for regarding these tumors as paragangliomas rather than ganglioneuromas or other suggested lesions are presented. Auf Grund von neun Beobachtungen werden die makroskopischen und mikroskopischen Befunde der Paragangliome des Duodenums beschrieben. Sie bilden von Schleimhaut überzogene Polypen, die maximal 2 cm Größe erreichen. Sie kommen vorwiegend in der fünften und sechsten Dekade vor. Histologisch setzen sich die Paragangliome aus Spindelzellen einerseits und saftreichen Epitheloidzellen anderseits zusammen. Mit der modifizierten Bodian-Färbung gelingt es, bei einem Teil der letzteren Neuriten nachzuweisen. Viele der saftreichen Epitheloidzellen zeigen auch Argyrophilie. Auf Grund dieser zwei Eigenschaften werden die Geschwülste den Paragangliomen zugeordnet.

Adenoid cystic carcinoma of the breast. An analysis of 21 cases

The clinical and pathologic findings in 21 patients with adenoid cystic carcinoma of the breast are presented. Nineteen of the 21 patients were living and well after treatment. Two patients died of unrelated causes. Local recurrence appeared in only 2 patients, 3 and 7 years following simple excision, but they were free of disease 9 and 14 years after subsequent mastectomy. No clinical or pathologic evidence of lymph node or distant metastasis was found in any of the patients. For these reasons, simple mastectomy is advocated as preferred treatment for adenoid cystic carcinoma, unless the tumor is particularly large or there are enlarged axillary lymph nodes. The favorable prognosis of patients with adenoid cystic carcinoma of the breast is in sharp contrast to that of patients with histologically identical tumors in other sites. Possible explanations for this striking difference in behavior are discussed.