Medullary carcinoma of breast, fourteen years without recurrence: Scirrhous carcinoma of opposite breast

MEDULLARY CARCINOMA OF BREAST, FOURTEEN YEARS WITHOUT RECURRENCE: SCIRRHOUS CARCINOMA OF OPPOSITE BREAST* PAUL KURT SAUER, M.D., F.A.C.S. Visiting Surgeon, City Hospital; NEW

Associate YORK

M

E., housewife, aged forty-seven years, was first seen on ApriI IO, 1935, com‘* pIaining of pain and a hard Iump in the right breast. She had noticed a sensation of the nippIe being drawn toward the midIine for severa months and had experienced pain for three weeks. At this time she noticed, aIso, a lump in her right breast for which she consuIted a physician, who advised a mastectomy. Previous history showed that the Ieft breast had been removed on September 26, 1921, and it was Iearned that at that time she had a very extensive invoIvement of her Ieft breast and the axihary nodes. The pathoIogica1 report from St. Luke’s HospitaI showed “the tumor to be a carcinoma with a tendency to form gIands, but in other areas it was distinctIy meduIIary in type, the growth as a whoIe showing great variation in morphology. The breast as a whoIe seemed to show many outIying areas of extension of the tumor aside from the origina growth.” No history of carcinoma in the famiIy was eIicited. The genera1 physical examination was negative. The Iungs were resonant throughout and no adventitious sounds were heard. Over the Ieft side of the anterior thorax was the Iong scar of the previous operation, we11 heaIed, soft, not adherent to the underlying structures and showing no evidence of any recurrence. The corresponding axiha and supracIavicuIar space reveaIed no paIpabIe nodes. The right breast showed a very hard mass in the inner, Iower quadrant, approximateIy 2 by 3 inches in size. The tumor was adherent to the skin which showed shght dimpIing, but the breast was freeIy movabIe on the thoracic waI1. The axihary nodes were not paIpabIe. RadicaI amputation of the right breast was being done on ApriI 18, 1935, the incision carried we11 away from the edges of the tumor. The patient was discharged after anuneventfu1 ConvaIescence on ApriI 27.

Surgeon, Lenox Hi11 HospitaI

CITY

The pathoIogica1 diagnosis by Bullock was “scirrhous carcinoma of breast, grade 2. No evidence of axiIIary invoIvement. Microscopic examination of sections through the noduIes show carcinomatous tissue, the stroma of which is abundant, dense, and poor in ceIIuIar eIements with areas of hyahnization. The tumor ceIIs are, for the most part, of smaI1 size, poIyhedra1 in shape and are arranged in narrow strands, thicker columns and irreguIar masses. Mytotic hgures are seen, though they are not numerous. The growth infiItrates the skin and deeper part of the nippIe. “Metastases are not demonstrabIe in six Iymphnodes which were found in the axihary fat .” COMMENT This is a case where, fourteen and onehaIf years after radicaI mastectomy for a meduIIary carcinoma with axiIIary metastases, an independent carcinoma of a different type deveIoped in the opposite breast. It is noteworthy that the majority of cases with axiIIary metastases at the time of operation do not survive more than a year or two. Exceptions to this, however, do occur. DISCUSSION DR. FRANK E. ADAIR (New York) stated that this is an interesting case in which Doctor Sauer has reported a rare circumstance, in that he has had the opportunity of studying the pathoIogic sIides of not onIy the origina tumor removed fourteen and one-haIf years ago, but, aIso, the tumor recentIy removed from the opposite breast. The tumor excised at the first operation was an adenocarcinoma, becoming infiItrating, grade II on the scaIe of maIignancy. In certain areas of the tumor

* Presented at the New York SurgicaI Society, 580

Feb. 12, 1936.

there was tremendous celIularity. This was, more especially noted in the metastatic areas in the axilIary nodes where the tumor

FIG. I. Adenocarcinoma

of Ieft September, 1921.

breast

removed

seemed to be even more mahgnant than in the breast. In the node cap$uIe, and even extending slightIy beyond the nodes, were areas of metastatic cancer ceIIs. Therefore, a remarkabIy good resuIt was secured in a case on the borderIine of operability and offering an especiaIIy grave prognosis. The pathoIogy in the opposite breast, recently operated, shows a duct carcinoma. These ceIIs differ from the first tumor. They are Iarge, cyhndrical, more opaque and granuIar with a great amount of oId fibrosis. Of especia1 interest in the Iater tumor is that the microscopic picture shows a11 stages of transition leading from a perfectly norma Iining ceI1 up to the cancer ceI1. There are areas of papiIIary overgrowths in the ducts. The factors which create the impression of deaIing with an entireIy different process in the second breast are (I) that it shows a11 transitions from the norma ceI1 to the cancer cell; (2) there is no trace of the first tumor; and (3) the cancer ceIIs themselves are entireIy different from the first type. Doctor Adair

thought it safe to assume that this w-as not a Iate recurrence but an entirelv new process.

FIG. 2. Scirrhous carcinoma of right breast removed April, I 935.

The question of biIateraIity of cancer of the breast always invoIves a probIem diffrcuIt of soIution. Cases of biIatera1 cancer occur under three circumstances : there is metastasis to the I. Where opposite breast. It usually takes pIace in the mesia1 portion of the remaining breast. The Iesion is usuaIly manifest within two or three years after the operation. The histopathoIogy is identica1 with the Iesion removed at the first operation. It is due to cross Iymphatic extension. 2. In connection with biIatera1 noduIar hypertrophic mastitis. AIthough this is rare, this type is occasionaIIy seen. The history is that the patient has had biIatera1 fibrous noduIar breasts for a Iong period. MaIignant changes become manifest in both breasts at about the same time, and usuaIIy in the tai1 of the breasts. 3. In circumstances similar to those presented by Doctor Sauer’s patient. This is a rare type. However, there are instances of carcinoma of one breast possessing muItipIe primary foci. These are well recognized. The several foci of origin seem

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to have no possibIe connection with, or extension from, each other, at times even being wideIy distant from each other. An exampIe of the Iatter condition of more than one focus in the same breast is afforded by certain cases of Paget’s disease of the breast, where there is one mahgnant process in the nippIe and areola, and another, entireIy different malignant process in the depths of the breast, entireIy separate, disconnected and even differing histoIogicaIIy from the nipple process. AI1 the factors responsibIe for the production of mammary cancer are not known. If they were, the expIanation of biIateraIity wouId be obvious. However, within the past twenty years there has been an enormous amount of study regarding the etioIogy of this major form of cancer. The experimenta contributions from the Iaboratory together with the carefu1 study of the various cIinica1 factors in each case, have made avaiIabIe the information that mammary cancer is not due to one cause but to several causes; and in a11 probabiIity to one or more factors working on the other. It is wideIy conceded that the ovarian hormones pIay an important roIe in causation. This is shown not onIy in the Iaboratory where castrated female mice fai1 to deveIop mammary cancer, but it is shown aIso in cIinica1 medicine where, for many years, it has been we11 recognized that mammary cancer deveIops but rareIy in ovariectomized women. FoIIicuIin and Iutein hormones from the ovary, and proIactin from the hypophysis, circuIating in the bIood, greatIy influence the celIuIar behavior of mammary tissue. It is thought, however, that this influence is greatest when the soil-the mammary tissue-is aItered by such inAuentia1 factors as those resuhing from duct stagnation and irritation secondary to non-nursing, to obstruction from scarring of abscess formation, to miscarriages, to inverted nippIes, the nonestabIishment of breast function, etc. The third great important factor is the “constitutiona1 factor” which is the inherent

of Breasts

MARCH, 193,

attribute which must be taken into consideration in a11 cases. It is that which makes the difference in the percentage of cancer incidence in breeding experiments. In one strain of mice these breeding experiments give consistentIy a definite percentage of mammary cancer, whiIe in another mouse strain the same identica1 experiments produce consistentIy severa times as many cancers. Cancer of the femaIe breast is dependent, therefore, on at Ieast three factors, each working on the other, nameIy, hormones; stagnation and irritation; and the “constitutiona1 factor.” DR. CARL EGGERS (New York) said that cases Iike the one presented by Dr. Sauer, of adenocarcinoma of the breast fourteen years without recurrence, and then foIIowed by a scirrhous carcinoma in the opposite breast, are of interest from the cIinica1 as we11 as from the pathologica standpoint. One shouId not fee1 discouraged too much when a patient develops a tumor in the opposite breast, or has a tumor in both breasts at the time. It is not necessariIy a bad sign. There are of course cases in whom biIatera1 invoIvement indicates advanced disease and who run a rapidIy fata course. On the other hand there are also cases in whom the prognosis seems to be no worse than in uniIatera1 invoIvement. The condition is not uncommon and I have had a number of cases in my own practice that have brought out interesting points. About two and one-haIf years ago, cIoseIy foIIowing one another, were 2 patients, one sixty-three and the other seventy-four years of age. Both had a biIatera1 tumor and both of them cIinicaIIy Iooked Iike carcinoma. In each case the breast on one side was apparentIy more extensiveIy invoIved than the other with enIargement of the axiIIary Iymph nodes. In the younger woman a radica1 operation was done on the more invoIved side, while on the other side a simpIe abIation with remova of the accessibIe axiIIary contents was done. Both tumors were reported

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scirrhous carcinoma with axillary invoIveWhether in such biIatera1 invoI\-ement ment on one side. In the oIder patient a the tumors appear to be identical in structure or whether they vary somewhat, radica1 operation was aIso done on the makes very IittIe difference. The interesting more invoIved side, but on account of her age her family physician wouId not permit whether the second question remains more than a wide IocaI excision of the tumor is a metastasis from the first one, tumor of the opposite breast. Both tumors or whether it is an independent tumor. In were reported scirrhous carcinoma without a case Iike Dr. Sauer’s, with an interval axiIIary invoIvement on the radicaIIy operof fourteen years, and definite pathoIogica1 ated side. Both patients have remained we11 evidence of difference in structure, one to date. These cases iIIustrate the we11 may assume that we are probabI;\- dealing known fact that if one is fortunate enough with independent tumors. On the other to get patients before the tumor has in- hand it is known that Iymphatics frevaded the surrounding tissue, or has ex- quentIy cross the median Iine and that tended aIong the Iymphatics to the nearest occasionaIIy one finds involvement of the lymph nodes, a Iess radica1 procedure than opposite axiIIary Iymph nodes. It is conthat usuaIIy employed, may cure them. ceivabIe, therefore, that in a certain perThe oldest Iiving patient in Doctor centage of cases involvement of the second Egger’s private practice with a biIatera1 breast must be considered as a metastasis carcinoma was originaIIy operated on in from the first breast. March, 1927 at the age of thirty-five years. DR. JOHN DOUGLAS (New York) felt that She had invoIvement of one axiIIary Iymph quite apparentIy Doctor Sauer was dealing node. In May, 1933 he performed a radical and not a metastatic with a separate, operation for carcinoma of the opposite tumor. One of the most interesting quesbreast. There was no axiIIary Iymph node tions in connection with Iate metastases is invoIvement. So far there have been no where the ceIIs have been during aI1 the further signs of disease. period before the metastasis occurred. In In stiI1 another patient., sixty-three years 1912 Doctor DougIas operated on a woman of age, scirrhous carcinoma of both breasts in St. Luke’s HospitaI for carcinoma of the deveIoped at an interva1 of Iess than a right breast. To the best of his recollection year. Both were treated by radica1 operathe axiIIary gIands were involved. In 1928, tion and on neither side was there axiIIary sixteen years afterward, she had pain in invoIvement. The patient was an old her Ieft chest and an aspiration was done cardionephritic case and succumbed to of this chest which was found to be fuI1 this condition in 193 I, about five years of bIoody fluid. Roentgen examination after the second operation. There was no showed a shadow fiIIing her chest, but it cIinica1 evidence of recurrence, but as was impossibIe to teI1 whether it was pIeura there was no autopsy performed, a positive or Iung that was invoIved. ShortIy afterstatement on this point is not possibIe. ward, she deveIoped a very small noduIe About six years ago in March, 1930 in the subcutaneous tissues in the Ieft Doctor Eggers performed a radica1 operaaxiIIary Iine, quite away from the breast tion for carcinoma of the Ieft breast on a and on the side opposite to that in which patient sixty-one years of age. Extensive she had had the breast tumor. This noduIe axiIIary involvement was found but in was removed under IocaI anesthesia and spite of that she remained we11 until May, the specimen brought to St. Luke’s Hos1934, when she discovered a Iump in the pital where slides were found to be identical opposite breast. This was Iikewise treated in a radica1 manner and was reported as with those made from the tumor of the woman’s right breast sixteen years premuItipIe carcinomata, Grade 2, without viousIy. The second tumor must therefore evidence of axihary invoIvement.

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have been a metastasis, and it must have metastasized in the left chest. Where were those cancer ceils during the sixteen years before they started to deveIop? DR. WM. BARCLAY PARSONS, JR. (New York) cited an interesting case in his experience. Seventeen years before he saw her the patient had noticed a Iump in her right breast. She had consuIted a doctor about it but he toId her to forget a11 about the Iump. Being a thoroughIy mode1 patient, she did. Then, during the course of a bronchitis, seventeen years Iater, the physician examining her discovered the lump in the right breast and when Doctor Parsons saw her, he noted an identicaIIy pIaced mass in the other breast. Each Iump was in the axiIIary tai1 and were of the same size. Each tumor turned out to be a scirrhous carcinoma. It is impossibIe to determine whether the Iump in the right breast was carcinoma a11 of the seventeen years or whether the patient had had the lump in the Ieft breast for seventeen years, but the fact remains that she did have a -tumor in her right breast which did not grow in the seventeen years since it was first noted. Operation was done nine years ago and has been folIowed by no recurrence. Individuals who happen to produce the type of tumor that is extraordinarily sIow in growth and metastasis, are, of course, most fortunate, and one might speculating upon whether, in long foIIow-up cases, the good resuIt is not due more to the particuIar habit of the particuIar tumor than to the surgeon’s good fortune in getting outside of the margin of spread at the particular moment of operation. DR. SEWARD ERDMAN (New York) asked whether the theory of the effect of ovarian hormone on breast tumors, practiced some years ago in Boston, was stiI1 being utiIized as a basis for advising oophorectomy in cases that are either hopeIess from the standpoint of complete remova or in young women where metastasis is frequent. He wondered whether Doctor Adair had had experience with oophorectomy as a form of treatment for cancer of the breast.

of Breasts

MARCH, L93?

DOCTOR ADAIR answered that a great deal of work aIong this Iine is being done at the present time and that the next five years shouId give forth some very interesting deveIopments. He said that the work of Loeb in ovariectomized animals was outstanding and that Loeb had obtained very much reduced incidence of mammiIIary cancer in those cases that had had the ovaries removed. DR. PAUL K. SAUER (New York) referring to Doctor Adair’s emphasis that the second tumor in his case showed morphoIogica1 variations from scirrhous to adenocarcinema, said that Doctor BuIIock, the pathoIogist at Lenox Hi11 HospitaI, had cautioned him not to Iay too much emphasis on the term “scirrhous.” Most breast carcinomas do not show uniform structure, and the periphera1 portions of most of the tumors diagnosed as scirrhous carcinoma are ceIIuIar, the parenchyma generaIIy predominating over the stroma. As regards foIIicuIin, I recoIIect two papers presented by Doctor Otto Pickhardt before the New York Surgical Society a few years ago; one on the experimenta production of carcinoma in mice by the injection of large doses of Iutein and the production aIso of chronic cystic mastitis. In the second paper, in trying to correlate this with humans, Doctor Pickhardt found that of IOZ cases of chronic cystic mastitis at Lenox Hi11 HospitaI onIy one patient had subsequentIy deveIoped a carcinoma. That case was diagnosed onIy cIinicaIIy because, for some reason, no histoIogica1 examination was made. Doctor Sauer said that it is d&cuIt to draw an anaIogy between animaIs and humans. SUMMARY I. Cases of adenocarcinoma of the breast with axiIIary invoIvement Iiving fourteen and one-haIf years after operation are rare. 2. In this case no recurrence was noted, nor were metastases found, fourteen and one-haIf years after remova of the Ieft breast for adenocarcinoma with extensive axiIIary metastases.

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3. A second tumor, aIso carcinoma but of a different structure and without axiIIary invoIvement, was discovered in the ocposite breast. 4. The pathoIogic slides of the first tumor fortunateIy were avaiIabIe for com-

QUACKERY (18th century), “universaIIy

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of Queen Anne,

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but in 1694 set up in the Strand his

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parison with the sIides of the second growth, thus faciIitating the proof of two &dependent neopIasms._ 3. There is no evidence to show that either tumor deveIoped on the basis of chronic cystic mastitis.

if not universal,

successfu1.” charIatans

American

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History

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