Howard A. (Howard Atwood) Kelly.

Gynecology and abdominal surgery online

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otjserved one fibro-angioma which clinically was compressible, very vascular on
section, and under the microscope contained so much vascular tissue in the stroma
between the parenchyma that I looked upon the tumor as an example of a mixed
angiofibroadenoma.

'Delage and Massabiau: Revue de Chir., xxv, No. 10.
^Thayer: Johns Hopkins Hcsp. Bull., Feb., 1906.




214 DISEASES OF THE FEMALE BREAST.

The recognition and treatment of angioma of the breast should not be difficult.
It cannot I)e mistaken for the angiosarcoma and the hemorrhagic carcinoma which I
will descrilie later.

Hydatid Cysts. — LeConte' reports an observation of his own and gives the
literature.

The diagnosis must rest upon the demonstration of the booklets. Clinically, the
picture is that of a chronic pyogenic abscess, of a doubtful tumor. The cyst usually
contains purulent material.

Encysted Foreign Bodies. — The example of an encysted secjuestrum from a
rib has been recordetl (p. 211). Clinically, it presented itself as a small area of in-
duration. The diagnosis was not made until the exploratory incision. In one case
of carcinoma of the breast I found the parasite of trichinosis encysted in the breast
and ])ectoral muscle.

Dermoid Cysts. — These tumors are rare; they may be in the skin or buried in
the breast tissue. The benign cyst never assumes the clinical picture of a malignant
tumor. If infected, it may resemble an abscess. The dermoid is recognized at the
exploratory incision by its distinct cyst wall, easily separable from the surrounding
tissues, and by its characteristic contents.

The dermoid may become malignant. Usually this change is associated with
involvement of the skin which allows a clinical diagnosis (this was so in my one
observation). If not, the wall of the malignant dermoid cyst is thick, fixed to
the surrounding tissue, and on section has the typical appearance of cancer.

FIBRO^EPITHELIAL TUMORS.

Among 333 lienign tumors of the breast 39 per cent, were of the fibro-epithelial
type: 27 per cent, intracanalicular myxomata, and 12 per cent, adenofibromata.

Intracanalicular Myxoma. — This most common tumor of the young female
breast is due to a liypertrophy of the periductal or intralobular stroma which develops
during puberty hypertrophy.

Clinically, the tumor may be single or multiple, in one or both breasts, of small
size, or it may appear as a large tumor, involving part, half of, or the entire breast.

Multiple Tumors. — In alwut 20 per cent, of cases the tumors have been multiple,
in one or both breasts. In the majority the age of onset has been less than twenty-
five years; in a few the multiple tumors had not been observed liy the patient imtil
after twenty-five, up to forty years. The clinical picture and the fresh appearance of
one of the multiple tumors does not dift'er from that of the single timior.

When the patient is under thirty the clinical diagnosis is not difficult, and, in my
experience, operation is not indicated unless one of the tumors is the seat of pain or
growth. The tinnor should be removed.

vSo far, in my observation, it has never been necessary to sacrifice the breast. I
have observed some of these cases fifteen years. The small multiple tumors have
given no further trouble. In some the breasts have lactated, and the tumors have
'LeConte: Amer. Jour, of Med. Sciences, Sept., 1901, cxii, 277.



BENIGN TUMORS.



215



not given any discomfort. I have noted before that if such a tumor is removed
during Lactation its parenclryma shows the - - -

characteristic hypertrophy of the physiologic
process present in tlie breast tissue.

When the patient is over thirty, it would
be difficult to differentiate multiple intra-
canalicular myxomata from multiple cysts.
In both cases, however, whether the tumors
are giving pain or exhibiting growth or not,
at least one should be explored and removed
for diagnosis.

Up to the present time I have never ob-
served either a carcinoma or a sarcoma in a
breast which was the seat of multiple intra-
canalicular myxoma. For this reason, in
the relatively very few cases in which the multiple intracanalicular myxoma is
observed in the breast of women over twenty-five complete removal of the breast is
not necessary to insure the patient against cancer or sarcoma.




Small Encapsulated Intracanalic-
ular Myoma.
Photograph of fresh specimen by Schapiro.




Fig. 466. — Medium-.sized Intrac.inalicular Myxoma, with Characteristic Sm-\ll and Large Lobula-
tions.
Female, aged thirty, tumor two j'ears. Photograph from painting of specimen.



216 DISEASES OF THE FEMALE BREAST.

Small Single Tumors. — In at least 70 per cent, the intracanalicular myxoma
has appeared as a small single tumor. The age of onset has varied between fifteen
and twent\ - five vears. Between twenty-five and forty-three I have observed a few
scattered cases. The tumor is freely movable, and, when it can l)e palpated, dis-
tinctly encapsulated; the majority have a characteristic lobulation and elasticity.
In a few instances the tumors have been smooth and tense, reseml)ling an adeno-
fibroma or a cvst. Growth, as a rule, is slow. The duration of the tumor has varied
from a few weeks to ten years.

Pathology. — At the exploratory incision the tumor has a distinct capsule (Plate

II, Fig. 1; and Fig. 4(j."i) and is usually lobulated (Fig. 466). The cut surface

exhibits roundish, bulging, myxomatous lobules of from 1 to

4» 'i ~ t/'- ' V*«- '^ mm. in diameter. The microscopic appearance

r: .^°c««*,, ,V^=S«': (Pig. 4(17) is sufficiently characteristic to recognize

'„-/\''^ ''^-^ "■^■, 'o^ '^' easily in the frozen section.

h^Y <!•■ ^ '^°' ! ^ ' In the vouny-er tumor one will observe, micro-

' '^ -A > '■<,'■'' y }' °^- scopicallv, more parenchyma; the epithelial cells

t. '''■ 'J^./'^ - ,"L^^^ ■'- ■'' will be of a higher type, and exhibit proliferation,
*; "o ° <^- ■. = ' 5' , « degeneration, desquamation. Given a

/ ^ ^^^ •?' V very small vouno' timior in the female

>-^ " a ?o' '\'° '■' .. breast, it will lie difficult to diff'eren-

•*^, ^ > .s . .'i , tiate macroscopicaUy and microscop-



n %



y



T^.



%



*■ ■ '■'''"' "" ■'' J /i.-ii' °.'.v icallv the cvstic adenoma, the adeno-

*■-*"« "^ . t" ^ t, c Z' ^ mvxoma. A differential diagnosis is,

'cy ■ '=°^. cj ° I A V ■ ' of course, of no practical importance.



.~>. oi« * ' .'^^ r " ^ ■ ^ "• '■■ fibroma, and the intracanalicular



!. ■ *V ^■. -■ ■ ■■ B •' 1 ^ • V.'. \/' . ? °

i' ' .s^ J ' . i, V 4, ', ( \ ]•'■'{ older the distinctly gross and micro-

\ \ : _ V \ '.■ f^x ' ■/: ''^, ' ■• ' scopic features of the tvpe become evi-

0:v ■ ' h- . ^ /^ ■•- - , «^- "ent.

L^ "^^ '-'.^ s /7^- ' •» ' " ' Treatment. — I am of the opinion

,„, , ,, that these single tumors should be re-

Fii.;. 4h7. — Intracanalicular Myxoma. o

Low-power microscopic drawing by Horn, iiioved. In the voungcr womcn re-

moval of such a tumor insures the
patient against the complete removal of the breast should this tumor l)e allowed to
grow to great size; and against the possibility of sarcoma, which usually takes place
when the intracanalicular myxoma has reached a large size. In the older woman
the operation is imperative, because a positive clinical diagnosis cannot l)e made.
Excision of the tumor, if it is encapsulated and has the characteristic appearance
of a benign neoplasm, is sufficient; but if the tumor looks very cellular, it should
be treated as a sarcoma (seep. 249).

Up to the present time, in about ten single, small, intracanalicular myxomata ob-
served in the breast of women between thirty and forty-three one has been a sar-
coma, cured by the complete operation.



BKNIGN TUMOKS. 217

The Single Large Tumor. — In about 10 per cent, of cases the intracanalicular
myxoma has involved half or the entire breast (Pig. 4GSj. With hw exceptions
the age of onset has been over thirty; the oldest, fifty-two. The duration of the
tumor varied from one to four years.

To illustrate my point that a single small tumor in the breast of a young woman
should always be removed, I cjuote the following example: A woman of twenty
observed a small tumor in the right breast; it required ten years for this tumor to
involve the entire Ijreast. An early operation would have prevented mutilation.

As the intracanalicular mvxoma grows lare-er its clinical diae-nosis is easier, the
lobulation and elasticity become more distinct, and, in spite of the size, the skin and
nipple remain normal. In my experience there should be no difficulty in dift'eren-
tiating the large intracanalicidar myxoma from the medullary carcinoma. The
latter would never reach such a size with-
out involvement of the skin. :^

Treatment. — In view of the ten- J

y

dencv of the large tumor to become a ^




sarcoma one should pay no attention to
its pathology, but be governed by the
chnical picture. Remove the breast, an
area of skin, and the major pectoral
muscle (see p. 274).

Pathology. — As the intracanalicular '

myxoma becomes larger and older one | .J

of two definite changes may take place: f i

one entirely benign, the other malignant.
The l)eniffn change manifests itself bv
the great increase of the fibrous trabeculte i'""- «s-LARr.E ixTRAc-.«ALicrLAK myxoma, right

^ Brf.ast, Simulating I'nilatkral Hypertrophy.

marking the lobules, by myxomatous de-
generation up to the development of cysts, and by the atrophy of the epithelial
parts of the tumors. The malignant changes take place in the myxomatous tissue;
the gross lobulation is lost, the tissue l)ecomes firmer and more cellular.

The largest tumors of the breast belong to the intracanalicular-myxomatous type.
The huge tumors found illustrated in the older monographs by ^'elpeau, Brodie,
Billroth, and Gross are of this character, and were called serocystic sarcomata.

Recurrent Intracanalicular Myxoma. — In a few instances, when a single
tumor has been removed, later one or more tumors of the same character may de-
velop in the remaining breast tissue. I should look upon such an observation as an
example of multiple tumors developing at dift'erent periods, rather than a recurrence.
Theoretically, this should happen frecjuently; practically, I have seen it on l)ut two
occa.sions.

Sponfaneous Disappearance of Intracanalicular Mijxovia. — In view of the com-
parative frecjuency of this tumor in the breast of young women and its rarity in older
women, and, so far as my observations go, its absence in the breast which is the seat



218



DISEASES OF THE FEMALE BEEAST.



of carcinoma, we may he justified in concluding that a small intracanalicular myxoma

may disappear.

I have never oljserved a carcinoma to develop in an intracanalicular myxoma.

Adenofibroma. — Clinically, like the
intracanalicular myxoma, we observe the
adenofibroma as a single or multiple small
timror, or as a single larger tumor. The
age of onset is the same, and in infre-
(|uency this tumor, either single or mul-
tiple, in women over twenty-five, resembles
the intracanalicular myxoma.

The single small tumor is rarely lobu-
lated, may be spherical, is quite hard in
consistency, and is usually associated with
pain and tenderness. It may be of rapid
growth. In quite a few cases the tumors
have remained cjuiescent for years. The
older the tumor, the more fibrous. Some
may become calcified. I am cjuite con-
fident that in a few cases of carcinoma
with a history of a quiescent, small tumor

of from ten to thirty years' duration, first observed when the patients were under

thirtv, the original tumor was an adenofibroma or a cystic adenoma.




Fig



ACCKSSORY BrKAST



469. — Fibroadenoma,
Tlssuk.
Photograph from Halsted's chnic (by Wright).
The tumor is clasped bj- the fingers of the nurse;
breast to the medial and lower side. (Clinical jiic-
ture hke unilateral hypertrophy.) Girl, aged nine-
teen, tumor nine m')nths.




Fig. 470. — Fibroadenoma.
Sketch of external appearance after removal from center of breast. Girl, aged sixteen, tumor six weeks. CUn-

ical picture that of unilateral hypertroph.v.



BENIGN TUMORS.



219



It is these observations which emphasize the importance of removing every







A,-#r-^



Fig. 471. — Fibroadenoma, Accessory Breast Tissue.
Gross appearance of section of alcohol specimen. See also Plate I, Fig 1.

single tumor of the breast, irrespective of the age of the patient or the duration of the
tumor. I have also one observa-
tion of a diffuse carcinoma in a f^^",' jr.{i^7r - ..~^.
breast the seat of multiple adeno- ^S^rt.""'.".'- '.-.,•;-.-; - . ^

fibroma of long duration. f^^^Sr" -' ' ■■

The adenofibroma never reaches ,■•:■.■;"■;- V;
the size of the larger intracanalicular •<;■■.:•• •- .;
myxoma, and, so far, has never been
observed in older women. The
larger tumors, when situated in the
center of the breast (Fig. 470) or
outside of the breast (Fig. 469)
(accessory breast tumors), may give
the picture of a unilateral hyper-
trophy. If such tumors are care-
fully studied at the exploratory in-
cision, the breast may be preserved.
In three of the cases sent to my
laboratory the entire breast had
been unnecessarily removed.

Pathology. — When the smaller
tumor is found in the breast of an
older woman, its hardness may
suggest a carcinoma, and when
explored, it may resemble a carcinoma to the inexperienced eye. A rapid frozen




■'^''i^mi






X,^-r*^^s;f



Fig. 472. — Fibroadenoma.
Microscopic drawing, L. Neilson-Ford. Fibrous tissue
excess; parenchyma undergoing atrophy.



220



DISEASES OF THE FEMALE BREAST.



section of an a(lenofi))roma may resemble at first sight a carcinoma, especially if
the tumor is fibrous and the parenchyma undergoing pressure atrophy.

This tumor always has a distinct capsule, which is absent in carcinoma. The
appearance of the freshly cut surface in the older fibrous tumors shows splits and
crevices without epithelial debris (Fig. -471). In the younger and in the larger
tumors the pink elevated dots of parenchyma (Plate I, Fig. 1 ) are distinctive features.
Microscopically the older tumor (Fig. 472) is characterized by excessive fibrous
stroma, and the parenchyma with the epithelial cells of a low type is under-
going pressure atrophy. In the vounger tumors and in the larger tumors of accessory
breast tissue the parenchyma predominates, resembling the picture of puberty hyper-
trophy, but not showing the normal architecture of the breast lobule (Fig. 473).




Fig. 473. — Adenofihrom.'V.
Photomicrograph by '\\' right. Young tumor, jtarenchyma in exces;



On two occasions I have found adenofibroma and intracanalicular myxoma in
the same breast.

BENIGN EPITHELIAL TUMORS,

Cystic Adenoma. — I have observed but five cases (1..5 per cent.). The age of
onset varied from twenty-eight to fifty years, the duration of the encapsulated tumor
from three months to five years, in breasts which hail never been the seat of lacta-
tion hypertrophy. All were small, freely movable, encapsulated tumors. At the
exploratory incision they could be recognized by the little cystic bulging from the
capsule (Plate II, Fig. 2) and by the minute cysts on section. The stroma is scanty.

Microscopically the picture resembles senile parenchymatous hypertrophy; there



PLATE II.



I




Fig. 1. — ^Small Intracanalicular Myxoma.
Girl aged eighteen, tumor eleven months. (Halsted's chnic.)




Fig. 2. — Encapsulated Cystic Adenoma.
Sketch from fresh tumor. Female aged twenty-six, tumor ten years. Excision of tumor. Well six years.

(Halsted's clinic.)



BENIGN TUMORS.



221






are adenomatous areas (Fig. 450), areas of ectasia (Fig. 4.51), minute epithelium-
lined cysts (Fig. 453), and adenocystic areas (Fig. 454).

The difTerential diagnosis of the benign cystic adenoma from the malignant
adenocarcinoma, at the exploratory incision, will be discussed later (page 227).

Twice, in breasts removed for carcinoma, I have observed multiple cystic ade-
nomata (Fig. 474) — unilateral in one case, bilateral in the other. The patient with
the unilateral lesion has shown no evidence of trouble in the remaining breast during
an observation of six and a half years since operation. The patient with the bi-
lateral lesion, who refused the removal of the remaining breast, died of carcinoma
of this breast five and a half years after the first operation.

Cysts with Intracystic Papillomatous Growths. — The interesting fact in
the clinical history of this l>enign cyst is the
discharge of blood from the nipple, which
is rarely absent, either in the history or
at the examination. There are eighteen
observations (5 per cent.) of the benign
form, while during the same period I have
records of fourteen cases in which the
papilloma had become an adenocarci-
noma (p. 231).

The possibility of a malignant trans-
formation must always be borne in mind.
The age of onset is about the same in
both the Ijenign and malignant form,
from twenty-seven to sixty-four years of
age. In the benign cysts the tumor had
been present from five to fifteen years,
while the longest duration of the tumor
in the malignant cyst was twenty years.
The duration of the tumor, therefore,
will not aid in the differential diagnosis.
In both there may be a history of a

small tumor which has remained quiescent for a number of months or years, and
then taken on rapid growth.

As long, therefore, as the tumor has not developed any clinical signs of malig-
nancy, the diagnosis must be made at the exploratory incision. In the benign cysts
the wall does not differ from that of a simple cyst (p. 207), the contents are either
hemorrhagic (Fig. 475), cloudy, or clear, never thick and granular. On opening the
cyst and sponging out its contents one can see or feel a papilloma projecting from the
wall (Fig. 476). This papilloma varies in size: it may be very small and the cyst
large, or it may almost completely fill the cyst. Its surface appearance is lobulated
and there will be no infiltration of the breast at the base of the papilloma (Fig. 47G).

A malignant cyst may be recognized by its thick, grumous, granular contents,




^'d






Fig. 474. — Cystic Adenoma.
Low-power microscopic drawing by Horn from
one of multiple shot-like tumors in a breast the seat
of cancer.



222



DISEASES OF THE FEMALE BREAST.



by the changed appearance of the papilloma, or by definite cancer nodules of the
eystwalUp. 231).

In my experience, it is best to remove the entire breast when a benign cyst with
a papilloma is exposed, because it is usually situated in the nipple zone, and the
nipple must be sacrificed. If there is any doubt as to its mahgnancy, the complete
operation for carcinoma should be performed.

I have observed this papillomatous cyst to be multiple in one case, and similar
observations are recorded in literature.

Discharge of Blood from the Nipple. — In both the benign and the malignant
papillomatous cyst this has been the symptom of onset in a few cases. In the ma-
jority the tumor has been observed within
a vear after the discharge was first noticed.
"-■ ' ■ , In one case the interval was three years; in

one patient no tumor could be felt at the
examination. The patient came to
the clinic because of discharge of
blood from the nipple, of five
months' duration. The pa-
pillomatous cysts were dis-
covered at the exploratory
incision.

I have observed three pa-
tients with discharge of blood
from one nipple which up to
the present time have shown
no evidence of tumor. In
one it is three and a half
years since the first symp-
tom ; in the others, two years.
If there is nothing but
discharge of blood from the
nipple, I am of the opinion
that such a patient runs no
greater risk without operation
than a woman without such a discharge. The probabilities are that a cyst will
develop. I presented the choice of an exploratory incision to these three patients,
but did not urge it.

Carcinoma.

It has been sufficiently emphasized that the surgeon should train himself to
recognize the malignant epithelial tumors of the breast at the examination. When
this is impossible, lie should learn to distinguish the benign from the malignant neo-
plasm at the exploratory incision, or from a rapidly frozen section.

It has been stated before that when a clinical diamosis of a malignant tumor can




Fig. 475. — Cyst with Intracystic Papillomatous Growth.

Section through breast and cyst showing hemorrhagic contents.

Female, aged fifty-two, tumor ten years.



CARCINOMA.



be made the complete operation should be performed without an exploratory inci-
sion. The signs which allow such a diagnosis have been given.




Fig. 476. — Section Through Breast and Cyst Showing Papilloma in Fig. 47.5.
The breast surrounding the cyst is senile: a few ducts beneath the nipple are dilated.

In the further discussion of carcinoma the gross appearance of the different forms
will be described, and this description will be the chief object in view. For purposes




I'iG. 477. — Microscopic Drawing of Base of Papilloma in Fig. 476, Showing Cyst Wall and Breast.



of prognosis statistical figures as to the curability of the different forms of carcinoma
will be added.



224



DISEASES OF THE FEMALE BREAST.



The complete operation for carcinoma should never he restricted, but it is of
interest to the surgeon to know the probaljle result.

Classification of Carcinoma. — For the purpose of diao-nosis from the fresh
appearance and for the comparative diagnosis, carcinoma of the 1 )reast falls naturally
into the following groups: adenocarcinoma, medullarv carcinoma, scirrhus, and
cancer cysts.

Operable and Inoperable Tumors. — In Halsted's clinic of the Johns Hop-
kins Hospital about 404 patients with primary carcinoma of the breast have been
admitted. In HS (27. .5 per cent.) the disease has been inoperable. Among these,
partial operations were performed in 72 cases ('17.2 per cent.). In every one of
these cases there had been undoubtedly an operaljle period.

This large proportion of inoperable carcinomata of the breast should be reduced
by the education of the public and the profession to the fact that every single tumor
of the breast should be explored and the indicated operation performed as soon as
possible after it is observed by the patient.

The ■nUimate rcsidfx in 210 cases which have been followed three years or more
since complete operation show that 42 per cent, have remained well three years and

more. In this number a few have developed
recurrences after an interval of three years
of apparent cure, reducing the percentage
to 35 permanently cured at the present time.
When the microscope has failed to find
evidence of metastasis to the axillary glands,
85 per cent, remained well three years, and
75 per cent, were permanently cured. This
demonstrates that absence of microscopic
evidence of metastasis in the removed axil-
lary glands does not exclude the possibihty
of death within, or after, three years from
metastasis.
When the microscope has found metastasis to the axillary glands, the percentage
of apparent three years' cure falls to 31, and permanent cures to 24. When the
removed supraclavicular glands showed metastasis, the percentage of cures is re-
duced to 10 and 7 respectively. These figures are given here in order that they may
be used for comparison when we study the percentage of inoperable cases and cured
cases in the different forms of carcinoma.

Adenocarcinoma.— The reladve frequency of this variety is 14.4 per cent, of
all cases. The number of inoperable cases is least; the percentage of cures, oreatest;
the relative number of cases which have been clinically doubtful and in which an
exploratory incision has been made, largest.

This gives an opportunity to study the effect of an exploratory incision into a
carcinoma. Among ten cases, in which three years or more have passed since the
operation, nine are apparently well — 00 per cent. ; one case remained well four years




Fig. 478. — Comedo-adenocarcinoma.

Section of alcohol specimen. (Patient of Geo. A.

McCallum, of Canada.)



CARCINOMA.



ana died of internal metastasis later. In this group the percentage of negative
microscopic examination of the axillary glands is greatest.

The age of onset in this group is between forty and fifty; in one case the patient
was aged twenty-seven, in one thirty-two; the oldest patient was seventy. Adeno-



Online LibraryHoward A. (Howard Atwood) KellyGynecology and abdominal surgery → online text (page 27 of 94)