Pseudo-recurrence after radical amputation of breast for carcinoma

NEW SERIES VOL.

III, No. 3

Section

diagnosis: Acute ture 103.6~~. Preoperative thyroiditis or mediastinitis, presenting in the suprasterna1 notch, possibly secondary to an esophageal perforation. Under locar anesthesia a Iarge abscess located beneath the prethyroid muscles, containing about six ounces of pus, was evacuated and drained. The abscess extended downwards beneath the sternum and aIong the trachea, but further expIoration was desisted from on account of the possibIe danger of breaking down adhesions or spreading infection aIong the ceIluIar pIanes of the mediastinum, if this condition had not aIready existed. Pus from the abscess cavity contained on smear in chains and GramGram-positive cocci negative baciIIi which on cuIture yieIded a Rlorgan baciIIus (coIon group). The first roentgen-ray pictures showed what was suspected clinically: (Ij a marked widening of the superior mediastinum in the region of the thyroid; (2) trachea displaced to the right and (3) a circuIar shadow I $5 in. in diameter in the Iower portion of the Ieft upper lobe which was unsuspected. Second roentgen-ray films six days later reveaIed the same shadow situated at the IeveI of the fourth rib anteriorIy and interpreted as an abscess. There were never any physica signs to make one suspicious of a puImonary Iesion. Aside from a sIight unproductive cough, the patient had no symptoms accountabIe for the roentgen-ray finding. He was discharged to be observed. About one week Iater he was readmitted with fever, cough, fetid expectoration hemoptysis, and high, remittent temperature. Chest signs were minimum. A roentgenogram showed a marked increase in size of the previousIy noted shadow which now extended from second to fifth rib anteriorIy. There was aIso noted a fluid IeveI. AccordingIy, under IocaI anesthesia, a resection of the fourth rib in the midaxiIIary Iine was done. The pIeura was entireIy seaIed off and a smaI1 rim of Iung tissue was found to overhe an abscess cavity about the size of an orange containing fouI pus. This cavity was Iined with gangrenous puImonary tissue. On straining, air couId be seen to issue from numerous smaII bronchia openings. Drainage was estabIished by rubber dam. The temperature came down to normal almost immediately; the pulse rate subsided graduaIIy; the wound granuIated weII; the smaII bronchia opening cIosed graduaIIy; and the patient was discharged four weeks

of Surgery

American

Journal

of Surgery

291

after operation with a granuIating wound, which later closed compIetely. Since that time he has been practically symptom-free. The wound has remained heaIed except during the period of an upper respiratory infection when the incision reopened and evidences of a bronchia fistula were present. The case is presented in an effort to obtain an opinion as to the sequence of events in this case. Did the puImonary suppuration antedate the mediastinal infection or vice versa and what was their causa1 reIationship? (No discussion) FAT

NECROSIS PERCY

OF THE

KLINGENSTEIN,

BREAST M.D.

B. J., female, aged thirty-eight years, was admitted to Mount Sinai Hospital, service of Dr. Berg, with a history that Iive weeks previously she first noted a lump in her right breast, unaccompanied by pain or discharge from the nippIe. There was never any history of trauma. No increase in its size was noted. Both breasts were penduIous. Just above the areoIa of the right breast there couId be palpated an irreguIar, finely nodular, firm, diffuse pIurn-sized mass, rather superficial but stiII appearing to take origin from breast tissue. It was adherent neither to the skin nor to the undedying structures. There was no nippIe retraction or enIarged axilIary gland. The mass was not easiIv dehnabIe but seemed rather to merge intimateIy with norma breast tissue. Preoperative diagnosis-carcinoma (?). Operation: Under genera1 anesthesia a two-inch radiaI incision was made over the tumor mass, which was compIeteIy excised. Section showed it to consist of infIamed and necrotic masses of fatty tissue. Microscopica examination showed a typica fat necrosis. I present this case not so much for its own interest, because both cIinica1 and pathologica aspects of fat necrosis of the breast have been adequately estabIished by Lee and Adair, but rather in connection with the next case which presents another form of fat necrosis of important clinica significance. (No discussion) PSEUDO-RECURRENCE AFTER AMPUTATION OF BREAST CARCINOMA PERCY

KLINGENSTEIN,

RADICAL FOR

M.D.

J. M., aged forty-seven years, entered the surgicaI service of Dr. Berg, hlount Sinai

292

American

Journal

Section

of Surgery

HospitaI,

of Surgery

for a carcinoma of the Ieft breast for which a radical mastectomy was done. Four months later she reentered the hospital because in the axiIIary portion of the wound just beIow the scar there was a rather hard noduIe, partiaIIy adherent to the skin, about the size of a Iive-cent piece. It gave the impression of fluctuation and was not quite as CharacteristicaIIy hard as a recurrent carcinoma noduIe. Impression: Pseudo-recurrence foIIowing radical mastectomy for carcinoma. Operation: Under IocaI anesthesia a number of smaII intercommunicating cysts situated in the subcutaneous tissues and containing fluid of an oiIy consistency, were excised together with an eIIiptica1 skin area. Microscopica1 examination showed inffamed fatty subcutaneous tissue with cyst formation. The picture akin to, if not actuaIIy that of, fat necrosis, was produced, we beIieve, by operative trauma. We have now coIIected a series of these cases, four of which were published by Dr. A. V. Moschcowitz’ and caIIed by him and Dr. Zemanskyz “ Pseudo-Recurrence,” has incIuded one in a recent articIe dealing with this subject. Just what eIement unabsorbed Iigature materia1 plays in the production of this pathoIogica1 state is diffrcuIt to determine. In one section an unabsorbed Iigature (catgut) is readiIy seen. It wouId seem as though both operative trauma and unabsorbed Iigature materia1, might produce the Iesion. CIinicaIIy these cases present diffrcuIt probIems. These noduIes are not quite as hard as carcinoma noduIes, are tense or ffuctuating and are usuaIIy quite tender. It taxes the diagnostic acumen of the surgeon to make a differentiaI diagnosis. On the one hand, excision of a recurrent carcinoma may be fraught with the danger of spread of the disease; on the other hand, we shouId relieve ourseIves of anxiety and the patient of an innocuous condition, should the lesion be a pseudo-recurrence. (No discussion)

SARCOMA

OF THE CALF MUSCLES

BOY AGED PHILIP

J.

FOUR LIPSETT,

The patient, a boy aged brought to my department

IN A

YEARS M.D.

four in

years, was the Good

‘Moschcowitz, A. V., CoIp, R., and KIingenstein, P. Late results after amputation of breast for carcinoma. Ann. Surg., 1926, Ixxxiv, 174-184. 2 Zemansky, A. P., Jr., andGottesman, J. Fat necrosis of heart. Ann. Surg., March, 1927, Ixxxv, 438-449.

SEPTEMBER, 192,

Samaritan Dispensary on January 3, 1927, for a painful swelling of the right calf. His previous and famiIy history were irrelevant. Present history: About two months before, about the middIe of November 1926, he began to complain of pain in the right caIf and the mother noticed the right caIf getting Iarger.’ The chiId graduaIIy lost his appetite, began to Iose weight, grew weaker and by Christmas, unabIe to waIk, he Iay in bed. AI1 this time compIained of pain in the caIf of such severity that he was unabIe to sIeep. The boy’s physica examination was negative with the exception of the right Iower extremity. The right caIf was uniformIy enlarged. The skin veins over the sweIIing were prominent. The swelling was painfu1, tender and tense. There was no induration. The mass was not adherent to the bones. The inguina1 gIands were paIpabIe on the same side. Temperature 101%. A tentative diagnosis was made of sarcoma or gumma of the soft tissues of the caIf. He was admitted to St. Mark’s HospitaI on my service for additiona study. Wassermann tests on mother and child were negative. The bIood showed a moderate anemia. Roentgenograms of secondary the chest were negative. Roentgenograms of the right Ieg showed a uniform swehing of the soft tissues of the caIf, the tibia and fibuIa giving norma shadows. A final diagnosis of sarcoma of the caIf muscIes was made. Dr. B. T. TiIton was consuIted. He concurred in the diagnosis and agreed that in view of the rapid growth of the tumor, and the paIpabIe Iymph nodes in the groin, the only therapy advisabIe was radiation. The chiId was discharged from the hospita1 and referred to the Radiation Therapy Department of BeIIevue HospitaI. The examining physician apparentIy disagreed with the diagnosis and the boy was admitted to the chiIdren’s ward with a diagnosis of deepseated infection of the right leg. Fortunately the attending surgeon did not agree. His diagnosis was aIso sarcoma. The chiId’s Ieg was amputated above the knee within the next few days. The patient went into shock but raIIied; and when I saw him a month Iater, he was markedIy improved. During his stay at BeIIevue, he received severa injections of CoIey’s serum. Neither radium nor roentgenrays were empIoyed in this case. The glands in the groin were stiI1 paIpabIe aIthough one