NEW SERIES VOL. VI, No. 6 Treves-Fibroadenoma of Breast American JWUI of surgery 78 I

cause a temporary reduction of kidney function. The increased function after the remova of the stone was surprising.

CASE III. F. C.: femaIe, aged twenty-nine years, came to the Fifth Avenue HospitaI with a history of attacks of genera1 abdomina1 pain and vomiting.

Her physica examination reveaIed nothing but a moderate amount of tenderness on pressure over the Ieft costovertebra1 angIe.

A roentgenogram revealed in the Iower caIyx of the Ieft kidney a smaI1 stone % inch Iong by $ inch broad.

The cystoscopy before operation November 7, 1928, reveaIed that the time excretion of phenoIsuIphonephthaIein after intravenous injection from the right kidney was three minutes and from the Ieft kidney was twenty minutes. No other comparative test of the renaI function was made.

The patient was operated upon and through a nephrotomy wound, a smaI1 stone was removed. Some diffrcuIty was encountered in finding the stone. The recovery was uneventfu1.

A cystoscopic examination after operation, December I, 1928, showed that after intra- venous injection of phenoIsuIphonephthaIein red appeared from the right kidney in three minutes and from the Ieft kidney in three minutes. The percentage phenoIsuIphoneph- thaIein and percentage urea at this examina- tion indicated that the Ieft kidney was apparentIy functioning better than the right. This increase in functional capacity on the part of the Ieft kidney is hard to explain after the remova of so small a stone.

The patient was admitted about a month Iater acuteIy iI and died shortly with a diag- nosis of bronchopneumonia. Autopsy showed acute yeIIow atrophy of the liver. There was apparentIy no relation between the kidney condition and this.

+a3

A CASE OF INTRACANALICULAR

FIBROADENOMA OF THE BREAST WITH ASSOCIATED TUBERCULOUS LYMPH/

ADENITIS MISTAKEN FOR CARCINOMA* NORMAN TREVES, M.D., F.A.C.S.

NEW YORK

T HE concurrence of tubercuIosis of caIIed attention to tubercuIar nodes in the the breast with carcinoma of that cervica1 regions mistaken for metastases organ has been extensiveIy studied. from Iaryngeal, pharyngea1 and IinguaI

KIose reported I 7 cases personaIIy carcinoma. observed. Other German authors, Bauer, An unusuaIIy interesting case reported Bundschuh, France, F . k rIc e and Schei- by WaIther has no direct simiIarity to degger have detaiIed such conditions. From the present one but shows multipIe Iesions the French Iiterature are the cases of Hart- in the same breast. mann and Massabuau, whiIe Rodman, Smith and Mason, Deaver and McFarIand

Th e specimen was from the breast of a

have pubIished histories of simiIar condi- woman thirty years of age. The lesion was

tions. In many instances the axiIIary nodes noticed ten months prior to operation but in addition a second nodule appeared near the

reveaIed metastatic mammary carcinoma periphery of the breast, which grew rapidIy, and tubercuIous Iymphadenitis. Leicher finaIly causing redness of the skin. There was

* From the SurgicaI CIinic, Fifth Avenue HospitaI. Submitted for publication ApriI 20, 1929.

782 A m&can Journal of Surgery Treves-Fibroadenoma of Breast JUNE, r~zz~

a tumor in the externa1 portion of the breast adenoma but the mode of infection was the size of a lemon, freeIy movabIe and nodular, not determined. apparently an adenoma, but a smaIIer nodule The only case in the literature which

FIG. I. IntracanaIicuIaI fibroadenoma of breast with excess of stroma compressing ceIIuIar elements.

near the areoIa was considered a scirrhous carcinoma. Microscopic examination reveaIed a fibroadenoma in parts, a ceIIuIar carcinoma in others and a smaI1 but typica area of tubercuIosis. The axiIIary lymph nodes were entireIy repIaced with cancer.

However, the incidence of tubercuIosis of the axiIIary Iymph nodes with benign Iesions of the mammary gIand has appeared to be a rare occurrence. Jehn, in reporting the resuIts of the autopsies upon 84 patients with tubercuIous axiIIary Iympha- denitis, found no benign breast tumors. A simiIar study by Prym faiIs to mention these co-existing conditions. Davis reported the case of an adenoma of the breast which, during pregnancy, became infected with tubercIe baciIIi. AxiIIary dissection faiIed to show invasion of the Iymph nodes and he concIuded that the case was one of primary invoIvement of an

FIG. 2. Section of another portion of tumor showing aIveoIar arrangement of acini.

appears simiIar to the one under report is that of RaveI. From his study he feIt that a11 adenomas of the breast are of inff amma- tory origin and concIuded that a fibro- adenoma of the mammary gIand associated with tubercuIous axiIIary nodes was of tubercuIar origin. The discrepancy in this case was not commented upon for the nodes appeared subsequent to the dis- covery of the tumor. Most cases of tuber- cuIosis of the breast are feIt to be secondary to a primary focus ekewhere and when the mammary Iesion deveIops secondary to axiIIary nodes it is concIuded that the infection is retrograde (Duvergey). But the case which is the subject of this com- munication had neither tubercuIous masti- tis nor was the adenoma invoIved in a tubercuIar process.

Mrs. M. M., an ItaIian housewife, aged twenty-eight, was admitted to the service of

NEW SERVES VOL. VI, No. 6 Treves-Fibroadenoma of Breast American Journal of surgery 783

Doctor Frederic W. Bancroft on November 24, 1918. She had been observed one week prior to admission because of pain in the right shouIder, present for two weeks. A few days after the onset of pain severa discrete masses were feIt in the right axiIIa.

The patient’s parents had died of causes which couId not be ascertained. Three brothers and two sisters were Iiving and in good health, as was her husband.

The past history was singuIarIy free of significant or reIevant compIaints. There had been no pregnancies though the patient had been married for four years. Menstruation was norma and the breasts had never caused any troubIe. She had influenza during the epidemic of 1918. A recent cough of three weeks’ dura- tion had been productive of occasiona bIood- tinged sputum.

Physical Examination. The patient was a weII-nourished woman with no obvious anemia. Her weight was 148 pounds, 8 pounds beIow her average weight. There was no hyperpyrexia and onIy IocaIized adenopathy. The examina- tion reveaIed onIy positive findings in the right breast, axiIIa and the Iungs. The breasts were we11 deveIoped and moderateIy penduIous. The nippIes and areoIae were normal, on a IeveI and equidistant from the midIine. The Ieft breast and Iymph drainage areas were without positive findings. In the right breast to the outer side of the areoIa a smaI1, sIightIy tender mass 2 cm. in diameter couId be paI- pated. This was discovered on examination but the patient was unaware of its presence. There was no skin retraction nor dimpling and the tumor was not adherent to the deeper structures. Low in the pectora1 region was a resiIient, non-adherent Iymph node 2 cm. in diameter and four Iarger ones, 4 cm. in size, were paIpated in the axiIIa. These masses were not tender.

Examination of the chest showed expansion equa1, reguIar, and without marked apica retraction. There was duIIness at the right apex extending down to the fifth rib and sIight duIIness at the Ieft apex. On auscuItation diminished breath sounds, bronchovesicuIar breathing and occasiona moist raIes couId be heard at the right apex. A bronchovesicuIar quaIity of the breath sounds was noted at the Ieft apex.

A tentative diagnosis of fibroadenoma of the breast and tubercuIar axiIIary nodes was made.

But complete bIood studies and a rontgeno- gram were requested.

The bIood findings were:

FIG. 3. Section from lymph node showing tube&e with typical giant ceI1, CbrobIasts and caseation.

HE. . . .

R.B.C.. W.B.C.. ~. P.M.N.

85 per cent 4,200,000

10,000 67 per cent 31 per cent

I per cent

The bIood chemistry was norma and the Wassermann reaction negative.

Roentgenological Report. Dr. Lewis Gregory CoIe and Dr. Robert E. Pound gave the foIIow- ing interpretation of the chest pIate: “ FiIm of the chest shows an infiItrative Iesion through- out the upper haIf of the right chest and the Ieft apex. The Ieft apex shows numerous caIci- fications, whiIe the infiItration in the upper right chest is of the soft type. I beIieve that this is a tubercuIous process and active at the present time.”

With these fmdings the tentative diagnosis seemed corroborated but a carcinoma of the breast was considered possibIe, and this was the preoperative diagnosis made by Dr. DonaId Gordon.

781 * merican Journal of Surgery Treves-Fibroadenoma of Breast JUNE, ,929

Operation. On November 28, 1928 a simpIe mastectomy and axillary dissection were per-

probabIy the secondary manifestations

formed under ethyIene anesthesia. Frozen of the puImonary infection. It was reason-

section showed the nodes to be of tubercuIar abIe to suppose, in view of the considerable

origin and the breast tumor an intracanaIicuIar Iiterature upon the subject, that without

iibroadenoma. surgica1 intervention the breast itseIf might

Postoperative recovery and wound healing have been invoIved in a secondary tubercu-

were without incident. Ious mastitis. Most authors have agreed

Pathological Report. Dr. D. S. D. Jessup that secondary tubercuIous mastitis has

reported on the pathoIogy of the specimen: resuIted from a retrograde emboIic process

“Macroscopicai Examination. First speci- through the Iymphatics. We may presume

men removed for frozen section is a node I by that the earIy operation precIuded such

145 cm. in size and on section is fiIIed with invoIvement.

caseous material. The breast is 16 by 13 cm., The tentative diagnosis was correct, but nippIe not retracted. About 3 cm. from the the preoperative diagnosis in this case nipple and beIow the deep fascia is an encapsu- lated nodule 3 cm. in size. Section for diagnosis

proved to be erroneous.

taken from this point. About 3 cm. from this It is a weII-established fact that buIky

noduIe is a smaIIer one about I cm. in size, carcinomatous axiIIary nodes may be

which is aIso encapsuIated and is fibrous on found without evidence of a primary

section. The axiIIary nodes, removed with the mammary Iesion or with a smaI1 insignifi-

breast range in size from 2 to 4 cm. They a11 cant focus of cancer in the breast. MaIig‘:

present much the same picture as the one nant tumors of the breast in young women

removed for frozen section. Some of these have are quite formidabIe and of a high index

only a capsuIe of node Ieft and are entirely of maIignancy. We feIt that we might have

filled with caseous material. been deaIing with such a condition in this

Microscopica Examination. The breast patient, who was onIy twenty-eight years tumors show a growth of dense fibrous tissue oId, having a smaI1 mammary tumor and between the acini and buIging into the tumor, spreading some of them out into narrow

Iarge axiIIary nodes. However, the axiIIary

channels. Sections of the Iymph nodes show adenopathy with such findings in the

tubercle tissue with Iarge caseous areas.” breast in the presence of active puImonary

PathoIogicaI Diagnosis. IntracanaIicuIar tubercuIosis might have Ied one to the

fibroma of breast; tubercuIous axiIIary Iymph concIusion that the nodes were of tubercu-

adenitis. Iar origin. With such a setting, in future

Subsequent carefu1 examination of the cases the more justifiabIe procedure wouId

specimen faiIed to revea1 any focus of tubercu- be an axiIIary dissection to determine the

losis in the breast. character of the nodes, foIIowed by a IocaI excision of the mammary Iesion if the

The axiIIary nodes in this case were nodes proved to be tubercuIar.