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Sarcoma of the bladder two cases
406
American
Journal
of Surgery
Stepita-Sarcoma
SARCOMA
OCTOBER,rgz8
OF THE BLADDER TWO
C.
of BIadder
TRAVERS
CASES* STEPITA,
M.D.
NEW YORK
T
0 the cases of primary
sarcomata ah-eady recorded in the medica literature, we desire to add two cases observed in the New York PostGraduate HospitaI. CASE I. J. E., maIe, aged four, admitted to hospita1 May 7, 1917, with history of dysuria for three months, being more marked at night, accompanied by frequency every two hours and with cIoudy urine. The pain on urination was accompanied by priapism and the stream was interrupted several times. Temperature on admission was 103.6’~., p&e g6 and respiration 24. PhysicaI examination showed a we11 nourished, maIe child, eyes and ears normaI. Abdomen showed a paIpabIe mass in the left Iower quadrant. Penis, semi-erectile. Rectum, negative as to palpation but pressure to left of prostate eIicited pain. Urine examination showed at different times a cIoudy or sIightIy bIoody urine with moderate traces of albumin, few white and red bIood ceIIs. A provisiona diagnosis of caIcuIus was made, but roentgenogram was negative for stones. BIood count showed 22,000 white bIood ceIIs with 76 per cent poIymorphonucIears. Cystoscopic examination reveaIed a markedIy trabeculated bIadder, with interna bulging of the Ieft latera waI1. The trigone was congested. The right and Ieft ureters were functioning. The urine from the bIadder was hazy. There was no evidence of vesica1 caIcuIus. Diagnosis of a Iow grade cystitis and papiIIoma of the bIadder was made. One week Iater a suprapubic cystotom y was done. A Iarge papiIIomatous mass invoIving greater portion of the bIadder was found. OnIy a portion of the mass couId be removed. The pathoIogica1 report: Gross, specimen consists of a number of irreguIar fragments, frequentIy hemorrhagic and having a coIIoid appearance; microscopic, the tissue fragments consist of an irreguIar mucosa of fibrobIastic ceIIs, which are of rather Iarge type and frequentIy show mitotic dividing forms. The genera1 appearance and character of these ceIIs * Read before Section
of Genito-Urinary
Surgery,
point to a neopIastic growth. They are, for the most part, spindIe shaped, and do not contain much interceIIuIar tissue. The bIood vesseIs are poorIy formed, and there are frequent foca1 hemorrhages. Diagnosis: SpindIe ceII sarcoma. Roentgen-ray treatments were appIied with IittIe improvement for about one month after operation. A piece of redundant tissue was snared off from the wound and the pathoIogica1 report was that of a myxoma, bordering on a spindIe ceI1 sarcoma. The growth was very resistant to roentgen-ray treatment, and a Iarge cauIiffower mass was soon protruding from the Iower edge of the wound. Patient died on September 13, 1917, after being four months in the HospitaI. Permission for autopsy was refused. CASE II. J. C. maIe, coIored, aged fortyeight. Admitted to HospitaI JuIy 30, 1926, with burning micturition and voiding bIood urine and clots for one week before admission, accompanied by nocturia during that period. The patient did not know of any exciting cause. The hematuria at times was quite profuse. Past history: Married, five children, a11 dead, cause unknown. Had Iues twenty-five years previously. Wassermann was negative for the last five years. PhysicaI examination reveaIed a we11 nourished, coIored man. Head, chest, abdomen negative. Inguinal Iymph nodes paIpabIe. ExternaI genitaIia negative. Urine examination showed at different times moderate amount of protein, red and white cells. Roentgenogram was negative for caIcuIi. Wassermann was negative. BIood count, 10,200 white bIood cells, poIymorphonucIears, 78 per cent. Cystoscopic examination showed cauIiff ower growth, posterior to trigone, about size of haIf doIIar, bIeeding profuseIy. At that time the growth was diathermized. Bladder was intoIerant. Some induration rectaIIy. Operation was performed on August IO, 1926, by Dr. McCarthy, suprapubic incision. Bladder was deIivered extraperitoneaIIy, opened and tumor New York Academy
of Medicine,
April 18, 1928.
Cave-Aberrant
NEW SERIES VOL. V, No. 4
Pancreatic
mass pIus about one-haIf inch of normaI bIadder waI1, surrounding neopIasm, removed. BIadder cIosed with suprapubic drainage. PathoIogicaI report: Gross, specimen is bladder tissue, measuring 50 X 40 X 30 mm., with a Iarge infiItrating tumor and a very smaI1 margin of heaIthy bladder tissue measuring from 6 to 9 mm. The centre of the tumor is necrotic. On section, the entire bIadder waI1 is infiItrated by a grayish white hemorrhagic tumor, which shows in its centra1 part, a demarcated area 15 X 18 mm. Microscopic, sections from the periphery of the bIadder tissue show at the edges transitional epithelium. The stroma beneath is edematous and i&Itrated with Iymphocytes and a few poIynucIear Ieucocytes with diIated bIood vesseIs. The entire naI1 is edematous. Approaching the
ABERRANT
Tissue
American
Journal of surgery 407
center, the surface becomes denuded of epitheIium and the underIying stroma is formed by an arrangement of spindIe ceIIs with Iong spindIe shaped nuclei. Between the ceIIs there are numerous fibers. The ceIIs incItrate the entire waI1 of the bIadder and onIy a few remnants of smooth, muscuIar fibers can be found as shown by Van Gieson stain. In the subserous Iayer of the bIadder one can find a bIood vesse1 with a pIug composed of ceIIs simiIar to those infIItrating the waI1. The centra1 area of tumor shows considerabIe necrosis but is composed of the same ceIIs as described. Mitotic figures are quite frequent. Diagnosis: SpindIe ceI1 sarcoma of bIadder. September 27th, 1926, bIadder cIosed. October 3rd, 1926, patient was discharged in good condition.
PANCREATIC TISSUE SIMULATING DUODENAL ULCER* HENRY
W.
CAVE,
M.D.,
F.A.C.S.
NEW YORK CASE
REPORT
History. Patient, sixty-four years of age, housewife by occupation, entered RooseveIt HospitaI, October 16th, 1927. Complaint. Pain in the right upper quadrant of the abdomen. Personal History. Patient has aIways been weI1, with no serious iIInesses. Operated upon five years ago for retroversion of the uterus. Present Illness. Began one year ago with vague feeIing of oppression and uneasiness in the right upper quadrant of the abdomen, not constant distress but worse at times, especiaIIy after doing her housework. As she describes it, “has a catch in her right side upon occasions with pain radiating upwards toward the Ieft.” Meat has increased her symptoms; she has vague aches and pains in her back; she has never had any definite attacks and no jaundice. Physical Examination. Patient is a we11 nourished, we11 deveIoped woman who does not appear to be III. ScIera cIear; heart and Iungs norma throughout; the abdomen is negative except for a definite tenderness in the right upper quadrant of the abdomen and
particuIarIy in the epigastrium just to the right of the midIine; no muscIe spasm, no rigidity; no masses couId be feIt; tenderness is sIightIy accentuated over the region of the galI-bIadder on deep inspiration; urine negative except for a few hyaIin casts on one occasion. BIood chIoride, 4.65; urea nitrogen 13.70; creatinine, 1.20; uric acid, 3.06; sugar, .115; bIood count, normaI. Roentgenogram Report. Urinary tract: PIain pIates made show the kidneys norma in size, shape and position and show no shadows in the region of the kidneys, ureters or bIadder that resembIe caIcuIus. GaII-hIadder: Plates made very faintIy visuaIize a smaI1, contracted gaII-bIadder with a poor concentraton of dye but without shadows that can be identified as gal1 stones. Additiona pIates made after the administration of food show the gall-bIadder compIeteIy evacuated. Diagnosis: There is apparently a patent cystic duct. The gaIIbIadder is smaI1 and contracted in size with poor concentration of dye. The faiIure to concentrate may be either functiona or due to some inflammatory mucosa changes in the
* Read before Section of Surgery, New York Academy of Medicine, December z, 1927.
American
Journal
of Surgery
Stepita-Sarcoma
SARCOMA
OCTOBER,rgz8
OF THE BLADDER TWO
C.
of BIadder
TRAVERS
CASES* STEPITA,
M.D.
NEW YORK
T
0 the cases of primary
sarcomata ah-eady recorded in the medica literature, we desire to add two cases observed in the New York PostGraduate HospitaI. CASE I. J. E., maIe, aged four, admitted to hospita1 May 7, 1917, with history of dysuria for three months, being more marked at night, accompanied by frequency every two hours and with cIoudy urine. The pain on urination was accompanied by priapism and the stream was interrupted several times. Temperature on admission was 103.6’~., p&e g6 and respiration 24. PhysicaI examination showed a we11 nourished, maIe child, eyes and ears normaI. Abdomen showed a paIpabIe mass in the left Iower quadrant. Penis, semi-erectile. Rectum, negative as to palpation but pressure to left of prostate eIicited pain. Urine examination showed at different times a cIoudy or sIightIy bIoody urine with moderate traces of albumin, few white and red bIood ceIIs. A provisiona diagnosis of caIcuIus was made, but roentgenogram was negative for stones. BIood count showed 22,000 white bIood ceIIs with 76 per cent poIymorphonucIears. Cystoscopic examination reveaIed a markedIy trabeculated bIadder, with interna bulging of the Ieft latera waI1. The trigone was congested. The right and Ieft ureters were functioning. The urine from the bIadder was hazy. There was no evidence of vesica1 caIcuIus. Diagnosis of a Iow grade cystitis and papiIIoma of the bIadder was made. One week Iater a suprapubic cystotom y was done. A Iarge papiIIomatous mass invoIving greater portion of the bIadder was found. OnIy a portion of the mass couId be removed. The pathoIogica1 report: Gross, specimen consists of a number of irreguIar fragments, frequentIy hemorrhagic and having a coIIoid appearance; microscopic, the tissue fragments consist of an irreguIar mucosa of fibrobIastic ceIIs, which are of rather Iarge type and frequentIy show mitotic dividing forms. The genera1 appearance and character of these ceIIs * Read before Section
of Genito-Urinary
Surgery,
point to a neopIastic growth. They are, for the most part, spindIe shaped, and do not contain much interceIIuIar tissue. The bIood vesseIs are poorIy formed, and there are frequent foca1 hemorrhages. Diagnosis: SpindIe ceII sarcoma. Roentgen-ray treatments were appIied with IittIe improvement for about one month after operation. A piece of redundant tissue was snared off from the wound and the pathoIogica1 report was that of a myxoma, bordering on a spindIe ceI1 sarcoma. The growth was very resistant to roentgen-ray treatment, and a Iarge cauIiffower mass was soon protruding from the Iower edge of the wound. Patient died on September 13, 1917, after being four months in the HospitaI. Permission for autopsy was refused. CASE II. J. C. maIe, coIored, aged fortyeight. Admitted to HospitaI JuIy 30, 1926, with burning micturition and voiding bIood urine and clots for one week before admission, accompanied by nocturia during that period. The patient did not know of any exciting cause. The hematuria at times was quite profuse. Past history: Married, five children, a11 dead, cause unknown. Had Iues twenty-five years previously. Wassermann was negative for the last five years. PhysicaI examination reveaIed a we11 nourished, coIored man. Head, chest, abdomen negative. Inguinal Iymph nodes paIpabIe. ExternaI genitaIia negative. Urine examination showed at different times moderate amount of protein, red and white cells. Roentgenogram was negative for caIcuIi. Wassermann was negative. BIood count, 10,200 white bIood cells, poIymorphonucIears, 78 per cent. Cystoscopic examination showed cauIiff ower growth, posterior to trigone, about size of haIf doIIar, bIeeding profuseIy. At that time the growth was diathermized. Bladder was intoIerant. Some induration rectaIIy. Operation was performed on August IO, 1926, by Dr. McCarthy, suprapubic incision. Bladder was deIivered extraperitoneaIIy, opened and tumor New York Academy
of Medicine,
April 18, 1928.
Cave-Aberrant
NEW SERIES VOL. V, No. 4
Pancreatic
mass pIus about one-haIf inch of normaI bIadder waI1, surrounding neopIasm, removed. BIadder cIosed with suprapubic drainage. PathoIogicaI report: Gross, specimen is bladder tissue, measuring 50 X 40 X 30 mm., with a Iarge infiItrating tumor and a very smaI1 margin of heaIthy bladder tissue measuring from 6 to 9 mm. The centre of the tumor is necrotic. On section, the entire bIadder waI1 is infiItrated by a grayish white hemorrhagic tumor, which shows in its centra1 part, a demarcated area 15 X 18 mm. Microscopic, sections from the periphery of the bIadder tissue show at the edges transitional epithelium. The stroma beneath is edematous and i&Itrated with Iymphocytes and a few poIynucIear Ieucocytes with diIated bIood vesseIs. The entire naI1 is edematous. Approaching the
ABERRANT
Tissue
American
Journal of surgery 407
center, the surface becomes denuded of epitheIium and the underIying stroma is formed by an arrangement of spindIe ceIIs with Iong spindIe shaped nuclei. Between the ceIIs there are numerous fibers. The ceIIs incItrate the entire waI1 of the bIadder and onIy a few remnants of smooth, muscuIar fibers can be found as shown by Van Gieson stain. In the subserous Iayer of the bIadder one can find a bIood vesse1 with a pIug composed of ceIIs simiIar to those infIItrating the waI1. The centra1 area of tumor shows considerabIe necrosis but is composed of the same ceIIs as described. Mitotic figures are quite frequent. Diagnosis: SpindIe ceI1 sarcoma of bIadder. September 27th, 1926, bIadder cIosed. October 3rd, 1926, patient was discharged in good condition.
PANCREATIC TISSUE SIMULATING DUODENAL ULCER* HENRY
W.
CAVE,
M.D.,
F.A.C.S.
NEW YORK CASE
REPORT
History. Patient, sixty-four years of age, housewife by occupation, entered RooseveIt HospitaI, October 16th, 1927. Complaint. Pain in the right upper quadrant of the abdomen. Personal History. Patient has aIways been weI1, with no serious iIInesses. Operated upon five years ago for retroversion of the uterus. Present Illness. Began one year ago with vague feeIing of oppression and uneasiness in the right upper quadrant of the abdomen, not constant distress but worse at times, especiaIIy after doing her housework. As she describes it, “has a catch in her right side upon occasions with pain radiating upwards toward the Ieft.” Meat has increased her symptoms; she has vague aches and pains in her back; she has never had any definite attacks and no jaundice. Physical Examination. Patient is a we11 nourished, we11 deveIoped woman who does not appear to be III. ScIera cIear; heart and Iungs norma throughout; the abdomen is negative except for a definite tenderness in the right upper quadrant of the abdomen and
particuIarIy in the epigastrium just to the right of the midIine; no muscIe spasm, no rigidity; no masses couId be feIt; tenderness is sIightIy accentuated over the region of the galI-bIadder on deep inspiration; urine negative except for a few hyaIin casts on one occasion. BIood chIoride, 4.65; urea nitrogen 13.70; creatinine, 1.20; uric acid, 3.06; sugar, .115; bIood count, normaI. Roentgenogram Report. Urinary tract: PIain pIates made show the kidneys norma in size, shape and position and show no shadows in the region of the kidneys, ureters or bIadder that resembIe caIcuIus. GaII-hIadder: Plates made very faintIy visuaIize a smaI1, contracted gaII-bIadder with a poor concentraton of dye but without shadows that can be identified as gal1 stones. Additiona pIates made after the administration of food show the gall-bIadder compIeteIy evacuated. Diagnosis: There is apparently a patent cystic duct. The gaIIbIadder is smaI1 and contracted in size with poor concentration of dye. The faiIure to concentrate may be either functiona or due to some inflammatory mucosa changes in the
* Read before Section of Surgery, New York Academy of Medicine, December z, 1927.