PROTOCOL

FOR

!.{)NTHLY SLIDES

November ,1957

'i'tl1·DR TISSUE REGISTRY

UlS A!JGELF:> COUl.ITY WSPITAL

12~

CASE NO, 1

ACCtSSION NO, 9J30

YA!It : C. P. AGS: 9 months

OONTRI!IUTOR:

TISSU!l FROI4:

SEX: Female RACE: Cauc ,

t/ , 'il . Hall, M. D. , Mercy Hospital, Bakersfield, Cali fornia.

Lung .

CLINICAL ABSTRAr.T:

Nove;nber, 1957

OUTSIDE NO. ~~67-57

History: 'lhis child was brought to surgery because of the finding of a chroni cally emphysematous left lov1e4• lobe which progressively enlarged and eventually caused almos t compleh atalectacis of the lef'·~ upper lobe, The mediastinum ~rae ehH't ed sharply to t he right, Weight gain had not been satis­factory and the ohild appeared to be failing,

Surgery: In !<larch, 1957. the entir e left l ower lobe was r emoved,

Surgical findings: At surgery, t here was a firm fibrous type of infil­tration along the right main bronchus, surrounding the pulmonary vein and con­tinuing into the pericardium,

Gross pathology: On sectioning the l~g. the right main bronchus appeared to be encroached upon by the f i brosing process and to become quite narrow a abort distance from the out end of the bronchus.

Follo~f-up: Postoperatively, the child did very •.tell . The left upper lobe expanned and filled most of t he pleural apace ,

CASE NO, 2 November, 1957

ACCESSION NO, 8693 OUTSIDE NO. A-82-56.

NAJ.!E: J, B, AGE: 9 SEX: ~iale RACE: Cauo,

CONTRIBU'IDR: Robert Cleland, ~l,D., Children's Hospital, Los Angeles, California,

TISSUE FROM: Brain,

CLINICAL ABSTaACT:

History: This child entered the hospital in April, 1956. tory of anorexia and lethargy of three to four months duration, occipito-frontal headache for three t o four weeks,

l{ith a his­He bad an

On physical examination bilateral papilledema, suboccupital tenderness and nuchal r~gidity 1~ere noted, !lhere were no cerebellar signs, no pathologi­cal toe signs and the ·sensory examination was negative, The child wa.s irri­table, but alert and fully oriented, Laboratory studies were negative,

On April 19th, 1956, a ventriculogram showed dilated symmetrical ven­tricles, The posterior 4th ventricle did not vi sualize.

Surgery: On April 26th, 1956. a posterior fossa exploration was done.

SUrgical findings: A whitish, firm, discrete mass 2 x 2 x 2 em, was seen on the floor of the posterior 4th ventricle, dumbelling through the fora­men, It was subtotally removed,

!lhe patient expired ]X)S.toperatively on the same day,

Autopsy findings: The brain sho~ted cerebral edema grossly and cere­bral and cerebellar herniation, There WaS a 2 X 2 X 2 em, portion Of the in­f .erior part of the tumor seen surgically, still present below the foramen mag­num, There was a 2 x l X' 1 em, fibrous l'lhite, discrete mass 1·1hich shelled easily from the left cerebellar hemispher.e, There ~te:i'e also discrete masses in the left parieto-occipital lobe and in the pons. Three discrete beads of tumor were noted in the cervical arachnoid,

CASF. NO, 3

ACCESSION NO, 8946

JiA!.IE: G. C. C, AGE : 6? SEX: Female RACE: Cauc.

CONTRIBU'I'OR: Ruth McCammon, M. D. , Los Angeles County ?.capital, Los Angeles, California.

TISSUF. FROM: Erain,

CLDHCAL AllSTRACT:

November, 195?.

OUTSIDE ro, 56-10529

Hiatory: 'lhis pe.tient had been under t he care of a private Jilyaioian for a number of years for scleroma and in July , 1956. lola& admitted to LACH because of lateral displacement of her left eyeball. Her na.Bal secretion had shown specificity to strepto~cin and her outside doctor felt that it had controlled the scleroma for some time,

While in the hospital, a spinal tap revealed a protein of 152 mgm.%. Skull series showed erosion over the left sphenoid ridge. ller E.E,G, was nor­mal and her angiogram inconclusive.

Surgery: On August 15, 1956, a left craniotomy 1me done, Tissue sug­gestive of tumor was seen in the middle table of the temporal bone and in the dura of the Sylvius fissure, A dural flap was turned and a large intradural extre.cortioal man was seen attached to the lateral and mid 2/3 of the sphe­noid ridge extending into the middle fossa floor and possibly the tentorium, Some of the tumor was removed en bloc and an equal amount re100ved by electric knife,

Gr ose pe.thology: The specimen consisted of an encapsulated lobulated mass measuring 6 x 5,5 x 2.5 em, 'lhe cut surface was firm, yellowish-white with a suggestion of lobulation, Also submitted were numerous grayieb-pink fragments of similar consistency measuring in aggregate 5 x 5 x 1.5 om,

CASE NO . 4

AOaDSSION NO, 9006

NAHE: A. M, AGE: 21 SEX: Female RACE: Oauc.

OONTRIBUTOR: Seymour :S , Silverman, M,D,, Memorial Hospital, Phoenix, Arizona.

TISStiD FRO!•!: Brain

CLINICAL ABSTRACT:

Novetnber, 1957.

OUTSIDE NO , D-3851-56

History: 'Ibis patient entered the hospital because of vertigo, weak­ness and loss of weight of nine months duration. ~e clinical diagnosis at one time was "multiple solerosis , u

No other history is available .

Autopsy findings: ~e brain weighed 1200 grams , There were no abnor­malit i es in the cerebral hemispheree,but on the ventral aspect of the medulla there was an irregularly sbaped,rubbery,firm tumor Which compressed the ven­tral portions of the cerebellar hemispheres. The mass arose in the medulla proper and was not an "angle tumor", The tumor and brai n stem together mea­sured 4 em, in greatest diameter . 1oJhen the cerebellum was removed, the tumor was seen to arise in the postero-inferior half of the floor of the fourth ventriole . Sections showed almost complete replacement of and expan­sion of the subs tance of tile medulla , The only grossly recognizable nerve fiber bundles were in the ventral area, ~e out surfaces of t he tumor showed fascicles of gray-white, rubbery , firm tissue,

CASE NO • .5

ACCESSION NO, 8667

NAME: L,H, AGE: 48 SEXs Female RACE~ Caoo,

CON'i.'RillU'roR: Meyer Zeiler, H. D., Midway Hospital, Los Angeles, California.,

TISSUE FROM; Retroperitoneal mass,

CLINICAL ABSTRACT:

November, 19.57.

OUTSIDE NO, M.578-.56

History: !!his patient bad had a subtotal hysterectomy seventeen yea.re prior to hospitalization, She had no current complaints, but a la.r~e mass had been palpated in the pelvis,

Sur~ery: In ~ay, 19.56, a. lower pelvic laparotomy was performed, A very hard ma.aa was found retroperitoneally in the hollow of the sacrum. It was located posterior to the rectum,

Gross pathology: and both ovaries,

The specimen consisted of a. retroperitoneal mass

The retroperitoneal mass was irregular and measured 11 x 8 x .5 om, It waa covered in part by SlllQOth glistening capsule; part of its surface was ganular and frayed , On section the surface showed two types of composition. At the center there was an irregular, ill-defined, hard wea. composed of criss-cross yellowish colored fibers, At th~periphery it was loose and areo­lar.

The ovaries wer~ received separately, !!hey measured 4 • .5 x 2 and 4 x 2 om,, had moderately convoluted and light yellow capsular surfaces. !!he sec­tioned surfaces showed ·ma.ny corpora. alba.ca.ntia. and no follicles •.

Follow-up: October 16, 19.57: Patient has been followed since time of surgery, approximately a year and a half a~ , Her pelvis is entirely nor­mal , !!he only complaints she has are hot flushes, undoubtedly brought on by ·the bill!.tera.l oophorectomy at time of surgery, Her general condition is fine.

CASE NO, 6

ACCESSIOU NO, 8987

NAME: L, M. AGE : 7} years ST. XI Female RACE: Ca1l0 •

CO!~IllU'l'OR: H, R, Irwin, .M, D, E. Conforth, M, D,,

November, 1957.

OUTSIDE 00 . c-725-9--56

Donald Sharp Memorial Community Hospital, San Diego, California.

TISSUE FRO~!: Retroperitoneal mass,

CLmiOAL Ai!STRACT:

History: In >larch, 1955, thie child fell from a bicycle and wae atruok in the lett abdomen by the handle bar. She complained of eyeuria and abdolll1-nal pain, Cellular elements ( type not stated) were found in the urine at that time,

Prior to the injury the child had also complained of eyauria and enure­sis. She had had urgency for several years and in August, 1956. complained of inoontilenoe on sneezing, In September, 1956, she developed a fever with her dysuria and on physical examination was noted to have tenderness to percussion over the left costovertebral angle,

Surgeey: On September 22, 1956, at surgeey, a tumor the size of an orange was found just below the lett kidney and it was necessary to remove the kidney to reach the tumor, The latter was very adherent to the upper psoae and quadrate 1\l!llborum muscles and appeared to invade the posterior ab­dominal wall, It wa.e believed to also extend into the crus of the dia];hragm, No metastatic nodules were found in the peritoneal cavity.

Grose pathology: ~e specimen consisted of an ovoid, moderately firm mass 9 x 7 x 6.5 om .. weighing 270 grams, It was covered by fibrofatty tissue and sharply circumscribed. The tissue itself was fH:rilla.ey, 1110iet, piDkieh­gray and partially demarcated into two lobules, one of which was twice as lar ge as the other. 'lhe kidney showed mild hydronephrosis and a depression on the undersurface of the upper pole where the tumor had compressed it .

Follow~up; October 21, 1957: ~is patient has vi sited her doctor in the last month, She has gained weight, haa no symptoms or signa at this time, and no evidence of recurrence of the retroperitoneal tumor.

CASE No. 7 November, 1957

ACCESSION NO, 9119 OUTSIDE NO, F-120o4,

NAI'IE: H, F, AGE: 69 SEX: lolale RACE: Oauc.

CONTRIBUTOR: Louisa Keasbey, H,D,, French Hospital. Loa Angeles, California,

TISSUE FROM; ~igh,

CLINICAL AllSTRAC'l'i

History; Oae year prior to hospitalization this patient noted a amall mass on the inner aspeot of the right thigh. It was removed at that tiDle and subsequently it re-appeared and increased in abe producing marked pain on walking, It was somewhat lnfl.a:mtd and hie anklea were swollen,

On }lh7s1oal eJaminat1on in January, 19.57, a large hard irregular mae a measuring 10 x 1.5 em,, was noted in the right anterior mid--thigh,

Surgery: On JanWlrY 1.5, 1957, the mass was excised along wi tb the ad-­ductor muscle group and the right femoral artery and vein.

Gross patholoQ"": !!he specimen meaaured 27 x 17 x 19 em. and wae attached to a akin ellipse measuring 19.oS x 15 om. Externally the maeu con~ siated largely of muscle. On out surface· it was lobul,ated and measured 13 x 8 x 8 em, ~e aurfacea .were yellowish, fibrous and nodular; occasional nodUles having undergone cystic· mucinous degeneration. Satellite masses extended from the maia tumor maaa, oae of these waa a finger-like projection measuring 1 • .5 em, in diameter and 6 om. in length. Grossly this latter resembled an en~ larged nerve, the fibers of Whfch had been separated and disrupted by tumor., In the center of the tumor was a major artery measuring 7 am, in diameter,

A fatty mass removed from the femoral triangle accompanied the specimen, It measured 2 x 2.5 x 1 em, and was free of nodes,

Follow- up: 'l'he patient expired on March 25th, 19.57,

Autopsy findings: No evidence of residual or metastatic sarcoma was found. The patient had in addition, rhetimatic heart disease with llllenoaia of the mitral and aortic valves and was markedly e!D()iated,

CASS llO , 8

ACCVSSION NO. 9360

NAME: V, G AGE! 74 S'CX: Male RACE: Cauc .

CONTRIBUTOR: C. B , Courville , M,D, . Los Angeles County Hospital, Los Angeles , California.

TISSUE FRot·l: Brain.

CLINICAL ABSTRACT:

November 1957

OUTSIDE NO. CC-1076

History: This patient was admitted to the Osteopathic Unit of the Los Angeles County Hospital on November 25th, 1956. in coma. He had fallen from a ladder three deys earlier and had h1t his head on a lawn mower. This was followed by headache, nausea, vertigo and projectile vollliting. He became comatose the morning of entry.

On }ilysical examination his blood pressure we.s 80/52, temPerature 102, 6, He had a stiff neok and responded to painful stimuli only. A spinal tap yielded 7 co . of xanthochrcni c fluid, pressure was 125 mm .H~. There were 261 Rbcs and 333 l'lbcs in the fluid . Protein was 84.5 mgm. ;b • sugar ~1as 4. 5 ~~. , Cl 90 mgo~. Gram posi t ive di pl ococci were seen on smear, but t here was no growth on culture media.

The patient was treated for pneumooocoal meningitis but did not respond and expired on November 27th, 1956.

Autopsy findingss At autopsy, lobar pneumonia and a tumor arising from the sella turcica were found. ~e brain was sent to Dr. C. B. Courville for further study, EXamination of the brain revealed a minimal atrophy of the frontal convolutions and softening of the left gyrus rectus consistent With a mild contusion,

~~e essential lesion was a tumor arising from an enlarged sella turcica and extending up above the sella in a roWlded mound of tissue ~lhich flattened the optio chiasm but had not resulted in demyelination of the optic nerves , The tumor had also grown throu&n the floor of the sella int o the sphenoid sinus where it appeared as a rounded mess, roughly the size of an olive. ~e actual measurel:~ents above the sella ltere 1.8 x 2. 3 em. and belov the sella 2. 7 x 2. 9 em. The tumor wae cut along the anteroposterior midline and showed grossly, granular tissue with a mild degree of necrosis suggested by faint yellow flecks. liha.t may have been remnants of pituitary were found in the lower and posterior portions of the mass , Tbe vertical measurement of the mass was 3 em, and the anteroposterior measurfr.11ent 2, 7 om. In the lower most portion there was a dark str eak of tissue representing either a focus of hemorrhage or some other structural change in the tumor .

CASE NO. 9 November, 1957

ACCESSION NO. 796) Autopsy No. 5?109

NAME: L. L, G. AGE: 10, SEX: Female RACC: Cauc,

COIITRllltm:JR: Dorothy Tatter, M.D •• Los Angeles County Hospital, Loa Angeles, California.

TISSUE FRON: Reaidual tumor.

CLINIC.~ ABSTRACT:

History; 1h1s child. vas seen for the first time at Rancho Los Amigo a polio division in April , 1955. because of an atro];by of the musclss of the right calf. Shortly thereafter e. popliteal tumor was noted. A biopsy of this apeoimen Bhowed sarcoma and the leg was amputated at the m.id thi@.h . Analysis of thiB specimen plus subsequent exploration of the sacral ple.xua revealed malignant achwannoma.

In November, 1956. a recurrent tumor of the stump was r emoved. Later that mon\h she vas re-ad!lli tted to the hosp.ital with intestinal obstruction due to band adhesions. At surgery, numerous large retroperitoneal nodules in the right lateral pelvis and an atonic bladder were noted.

Fbllowing this , the patient's condition deteriorated gradually and abe waa ad!llitted to the Los Angeles County Ilospi till for the last time on l•larch let, 1957 and expired on March 18th, 1957.

Autopsy findings: 1he main mass of the tumor measured 18 x 10 x 7 em. and had a lobulated appearance, The inferior portion of the tumor was covered with a necrotic exudate corresponding to a portion which protruded externally over the posterior portion of the greater trochanter.

1he cut surface vas rubbery, firm, white and whorled with areas of hemorrhage and small areas of fat. Near the spinal cord the nerves were ex­panded with tumor tissue. One large nerve, probably the sciatio, extended from the main mass and waa greatly expanded with tumor even aa it antered the cord,

Tbe spinal cord at the anatomic level of Tl2 presented a bulging tumor 4 x 2 x 2 em., located beneath the dura and on out section appearing to encircle tl!e cord. On palpation the diatal cord and cauda equ1na appeared to contain subdural tumor.

The aa,1or portion of the maae lay withi n tha pelvis to the right of the rectum and internal genitalia. 'lhe tumor spread r etroperitoneally over­lyi nc the sacral hollow, 'lhere were nodes alone the iliac veeeela, all of Wblch did aot appear groeal.Jr involved by t umor. However, section of one nodule did reveal a celatinoua, ~eb-white mass.

NOTE: Surflical material on the above cue was presented as Case lio. ) in the September 28th,l955 monthly Confere110e.

CASE NO, 10

AC.CESSION NO, 9161

NAJ.!E: A. P, AG-E: 38 SEX: Female RACE:

CONTRIBUi'OR: · E, 14, :Sutt, M.D., St . Luke •s Hospital, Pasa.dei!B., Ce~ifornla ,

TISSUE FROM~ l~erve,

CLDfiCAL ABSTRACT:

November, 195?

OurS IDE NO. 22~57

History: This patient had been born with VonRecklinghausen 1s disease, At an 1llllmown t ime she had developed a callous on the sole of her foot ~1hioh had not bothered her until just prior to hospitaliza tion when she developed a locali zed abscess, which she had had biopsied,

Physical flndings incJ:uded a 1, 5 om, freely movable, :firm and slightly tender nodule over the left scapula. '! he left leg 1tne involved in a· process of neurofibromatosis with fairly l a rge are~s of pigmenta tion over the lower leg, There was soft swelling in the tissue beneath these pigmented areas . Over the ball of the :foot on the left side , there was an almost cartilaginous area of calloused skin. The rest of t he body showed o. fe1., other scattered areas of pigmenta tion,

The Tumor :Soard recommended that the portion of the leg involved by lymphadenitis be resected,

Surgery: November 2, 1956. Excision of planta r sinus and resection of 21ld and 3rd toes ,

January 18, 19.5?. Excision of nerve tumors and redundant tis­sues of :foot and ankle , At surgery, it tlas found that the entire left lower thigh, leg and foot were involved in a mrked redundancy of skin and subcutan­eous tissues , There was a nerve tumor of t he medial plantar flexus, the size of a potato on the sole of the :foot, This was continued with a tumefaction of the tibia l nerve which 11as traced to the midcalf.

October 9th, 1957, Further excision of tumors of the left leg with skin graft,

Gross pathology: January 18th, 195? surgery - The specimen consisted of multiple, irregular skin and subcutaneous masses to ~1hich elongated nerve tumors ~/ere attached. The specimen included large masses of corrugated, thick skin with subcutaneous tissue plus an encapsulated pear-shaped edematous tumor ~~d three disarticulated toes, The pear- snaped mass weighed ?8. 5 grams and measured 10,5 x 5 x J,5 em, On cut surface this tumor had a. variegated appear­ance ~lith areas of firm, yellow tissue alternating with almost cystic areas With gela tinous contents.

Two segments of nerve trunk and tumor measuring an average of ll • .5 em . in length and 1 • .5 om. in diameter , were present , They were cylindrical , branching and appeared well encapsulated as if growing ~~ithin the sheath of the nerve itself,

The remaining and principle portion of the. specimen consisted of skin and a. bulky neural tumor weighing 360 grams. The skin here varied up to 2 em,

continued.-

-2-

CASE NO, 10 - Accession No, 9161 - continued,

in thickness, The tumor attached to the akin had multiple root-like branches which appeared to correspond to the branchings of the principle plantar nerve, The branches measured up to 11 em. in length and 5 om. in diameter.

Grose pathology: October 9, 1957 surgery-: '!hie specimen consisted of segments of epidermis and subcutaneous tissues along with a sinuous mass of branching cord-like tumor weighing about four pounds. These cords varied in length up to 46. em,, a.'ld in thickness up to :3.5 om, On cut surfaces they were composed of glistening encephaloid tissue which in places formed large nerve fiber trunks ~~ithin the main cords,

The epidermis in some of the segments presented a diffuse cafe au lait discoloration without any distinct cafe au lait spots. The subcutaneous fat in some of the segments appeared to be irregularly- thickened ~lith grayish­white fibrous tissue forming trabeculae.

CASE NO , 11

ACCESS ION NO. 91148

NAME~ ~I.G ,

AG!!: 8 SEX: Female RACE: Cauo .

OONTRI:BUTOR: Seymour :B, Silverman, M,D, , l'ft!mo rial Hospital, Phoenix, Arizona,

TISSUE FROI·It :Brain.

CLINICAL AllS'l'RACT:

November , 1957

OUTSIDE NO. CA. ?6-57

Bietoey: 'l'bis child had complained of intel'lllittent vomiting since Ootober , 1955. ( eignteen months prior to death) . She had had diplopia and f requent headaches for several months ,

On physical examination she had marked bilateral papilledema of 4 to five diopters and hypo-active tendon reflexes . 'l'be X- rays of her skull were normal. A neurosurgical consultant reported a "picture of marked increase of intraore.nie.l preseure and eigne euggeeting a midline me.se, possibly e. medullo-bla stoma". The child expired without craniotomy.

Autopsy findings: The positive findings were confined t o the brain, There was a large midline tumor mass e.riei ng from the floor of the fourth ven­tricle and expanding dorsally and ~ard. There was marked compression of the cerebellar bemiepherea and the tumor presented posteriorly between the cere­bellum and upper cervical cord, The third ventricle was occluded and the lateral ventriolee showed marked hydrocephalus ,

CASE NO. 12

ACCESSION NO, 948.5

NAME: A, R. AGE: 28 SEX: Male RACE: Ca'UO,

CONTRIBU'IOR: Seymour B. Silverman, I~.D .. ~~morial Hospital, Thoenix, Arhona.

TISSUE FROM; Mass in neck,

CLINICAL ABSTRACT:

November, 19.57.

OTJrSIDE NO. 5-240-,567

History: This patient had had a mass on the left side o! his neok tor approxilll&tely siX years.

Surgeey: Tbe mass was el!Ciaed on November lJ, 19,56. The inferior pole vas attached to the deep tracheo-esophageal sulcus a.rea and laq between the common carotid artery and the vagus nerve and jugular vein.

Gro.sa pathology: The specimen was an ovoid maea mea-suring 7 x .5 x 4 om.,. covered b:; a . thin fibrous like capsule, Tbe cut surfaces were light yellov­graq and fish-flesh in appearance, with foci of myxomatous and edematous de­generation.

Follow-ups October 1.5, 19.57: Complete recovery, with no evidence of recurrence or complications.

Rmi:>RT ON THE

STUDY GIDUP CAS!S

FOR

NOVBMBER, l9.57.

CASE 50, 1 , ACCESS I ON NO, 9))0 , W, W, Ball, M,D, , Contributor.

I.OS .AllG ELKS 1 Aadgned disouallOI' •a di agnosis: Intlai!IliiEitoey process in lUD.g,

General diaouaaion and alternate d1ocnosea:

(1) PulmoDBry or bronchial bamrtoma with prozdnent neural oo~nent, (2) :SronobopulmoDBry sequeatmtion, Thil 1e uauo.lly left-aided and

repreaenta BD extra, nontUIICtiODBl pul1110nary lobe which tende to 1ncreo.ee in ahe. It wa.a Ukened to the ancrosom1a often aeeooiated w1 th vo11Baold1nc­he.uaen '• disease. 'lhe nelll'al overgroWth lllBY be balic in thh abnoJ'IliBl.ity. The vote was unnnimoue for bronchopullllODBrT aequestrnt1on,

om.A]!D& Vottng waa even between gnnglioneuromatoaia , ganglioneuroma and hamar­

toma of neurogenic t iaaue.

SA! DI!i!GO: All agreed that this lllUBt represent some type of developmental anomaly

or hamartomatous lesion.

CEIITJ!.AL VeU.EY: Ih discuaaing this case, it wna noted that the slide in the aet of one

of the member& conta ined pract1oall7 nothing but a telectatic and elllfb7aematoue lun& and it was auapscted that maD7 of the elides rtJC.'J' not have been as entia­factory a s those oritiDBlly studied by the contributor, Moat of the members bad mde a diagnode of neural b.o.llnrtoma from their own seta, However , it wne the oonseneua that the contributor 's dia&Dolie of eang].ioneuroblaetoma waa probabl7 correct, 'lhe vote -hamartoma, compatible with gangl1oneuro-bl astoma - 7,

PILE DIAGNOSIS! :BronchopullllOnary 1equestrat1on, Cross tilde: Ballnrtom.

C,ASE NO, 2 , ACCESSION NO, 869), Rober t Clel and, M,D., Contributor,

:I.OS .AllGlliLES: Aa'at&Ded diacual or'a diagnoaia: Medulloblaatomn.

General diaouaaion and alternate d1agnceeat Ependymoblastoma, 'lhe vote was unanimous for medulloblaetomn.

continued,.

caae llo, 2, .Aooesdon No, 8693 - continued,

QAU.e'flD;

Medulloblaatoma 7, epe~m 3.

SAil DD!QO: At7Pioal medullob1aat01116 6, epenQIDoblaatom 3.

CEll?'!!e!, V ATJJ!!Y; 'lhe diaouaalon of this case ~duced acnament that the olaelitioation

of theee midline subtentorial cellular tumors in children is in a aomevbat uneat1etaoto17 etate. 'lhue a tumor submitted b;r one of the group tor Dr .• Kernahan '• State Contere~~ee, VIlli or1C111Cll7 olau1tied b;y Dr. Kernohan as an epe~oblutom. Dr. Xernohan then rejected both the contributor'• d1aenoa1e of medulloblastoma and the alternate pouibiUt;r ot 1ntrao:ran1al saroomo.. Hov­ever , on re-rev1ev of the BllJDe oa.ee eeveral 1eare later Dr, Kernahan felt that the dia&noe11 of 11111dulloblaatom vaa the moet rea~~oaable one. { Rat. 1, oa.ae 3 ), '!he Caaa No. 2 in the current aet drew tour votee tor medulloblaatoi!IB and three tor epend;rmoblaltoiiiB. baa who favored the latter di~osia emphnaized the lliiiOU:nt of appareutl;r axtraoellulazo tibrilltLI7 IIIBterial and the aucgeation ot papillal7 pattern in some 81'8811e 'lhoaa vho favored the former al!IJhaalzed the shape ot oelle and nuclei and the 1111n1ncea1 cl1olll8toa1a. It wna felt that thh ditferanae in pretarred words did not involve an;r particular difference in rec­ognition of the leaion. 'lhe queat1on of the relative radioaenait1vit;y of me­dulloblaetomo.e and epend;rmoblaatoma~ wa e railed. It wna felt that both were decidedl;r radioeeneitive.

FILE DU!tNOSIS : MedulloblaatOIIIBe Crose tile 1 Rpend;rmoblna toma,

OASB Ill, 3, ACCESSION Ill . 8946, Ruth M:!CIImmon, M,D. , Oontributor.

LOS A!fGEL!§: Auignsd dieoueaor 1 e diaC)1oeiB: Sclerolll8e

General disouaalon and alternate diagnoaee: 'lhe hietolog;y 11 typioa.l ot the third atage of 1oleroma, showing relat1vel;r tew remaining Mikulioz 1e oella. Warthin-starr;r stain shows the vonFriach bacilli (Friedlander'•). The lea ion 18 rare in the cranial cavity thoueh it 1a said to have occurred in South American caeee where the dileaee appears to be of a more aoti,ely in-'m8iva t;rpe, 'lhe vote VIlli unanimoue tor aolerom, intracranial extendon.

oep.mp; Inflammatory lesion coneietent with eol eromn 4, fibrous meninci oma 3.

lipoid bietioc;rtoai• 1, no opinion 1,

SAl! DimO; Granuloma, aecondary to rhinoscleroma, 7 votee, lipoid granuloma 1

,ote. no dia111oail 1 vote. (Dr. Contreras of Tijuana stated that rhinoaoleroaa was relatively common in Mexico and tha t this lesion resembled oases that he baa aeen in histology although not in location).

oontinuetl.-

-3-

' Case Bo. 3, Accession No. 8946 - continued,

CENTRAL VALLEY: After aevernl members bad offered tentative diagnoses of odd meningioma.

in this case, Dr. Blanchard eave his reasons for considering this lesion an intracranial scleroma, Ha stated that a eu:perficial search of the literature had failed to reveal reported instances of appearance of intracranial acleromB after apparent control of nasal ( rhino) scleroma, However, he felt that the foam cella in this lesion were readily interpreted as Mikulicz cella, that acme of the crystalloid hyaline maaaea resembled Rusaell bodies and that the dense hyaline fibrosis anA the aggregatea of plaema cella likewise accorded vell with published deaoriptione of rhinoscleroma, He cited an excellent diacusaion in Herbut 1e Textbook of Pathology, Another member gave on additional reference: llaltroe,Hamilton, Floyd,Mufti e, Imon, Annals of Otology, Rllinolog and le.ryn­golog:y 63, 1031-1055. 1954-. Five ot the group accepted Dr. Blanchard's diag­nosis. There remained one vote each for meningioma and chordoma.

FILE DIAGNOSIS: Scleroma, intracranial extension.

CASE NQ, 4, ACCESSION NO, 9006, Seymour B, Silverman, M,D,,Oontributor, '

IDS AliGELES: Assigned disousaor •s diagnosis: Ependymoma.

General discussion and al terna.te diagnose•: (1) Polar epongioblMtoma, (2) e.stroc:;toma, grade III, Diagnostic differences are based largely on var­iance in terminology thoU&Jl the spindle cell, bundled character of thie tUIIIor seems to aet it apart, The vote: Polar epongio'blastorno. 8, astrocytoma, grade III, 1 vote,

OAKMND;

Malignant echwa.nnoma 1, gl.iobl!letoma mul tifol'me ( astrocytoma grade III). 9 votes,

SAN DIEGO: Astrocytoma, Grade IV, ol' glioblastoma multiforme 7 votes, apongio­

ble.'stomo. polare 2 votes,

CENTRAL VALlEY: The member who sent in his vote bad termed this case a malignant aohwe.n­

noms, All the members present at the meet ing considered that tumor was essen­tiallY astrocytic. The principal problem was that of the classification of the large cella somewhat resembling nerve cella, Cells of not too dissimilar appearanoe a.re accepted as a matter of course in high].:; anaph.stic satrocy­tomaa ( glioble.etome. multiforme), bUt some of the group felt that. the fBIJ010'Q­lated a.rcbitecture and the over--all cytology of thh tUIIIor were not those of very high grade astrocytoma. Three members therefore favored the term neuro­c:;tome., The:; concurred with the general remarks about thia possibility in the faeciole by Kernohe.n and Sa:;re . and used the term in a descriptive and not ne­cessarily a histogenetic sense. ~e other three preferred the simPle term astrocytoma. !!he grading would be placed somewhere between II ond III.

FILE DIAGNOSIS: Polar spongioblMtome., Orcas-index: Astrocytoma, Grade III.

nesE NO, 5, ACCESSION NO, 866?, Meyer Zeiler, M,D,, Contributor,

.WS ANGJ:LIS 1 A.Baigaed diaounorfs diag~~osis: Hamartoma.

General di1cuasion and alternate di&gnoi8SI (2) Solero1ed tumor of unreoogDizable origin, (3) vote vae uaanimoue for sclerosed fibroid tumor,

Qtl!.AND:

(1) Sclerosed angiofibroma, Fibrous mBaothelioma. 'l'he

Retroperitoneal aolerosing hemangioma 2 , oenign ·retroperitoneal llliiSo­thel1oma l, sclerosing granulom l, !DIIn111g1ome. 5.

SAN DIEGO: Four members felt that tbia lesion reaemhled parte of Case No, 12 in

this set and favored a diagnosis of hyalinized neurilemmoma. Other diagnoses vera leio~oma of vascular origin 2 votes, degenerated leiorqoma 2 votes and hemngioma perioytoma 1 vote,

CEN'D!AL V AT.T,EYt In the initial discuesion on this case, the maJority favored some sort

of mBaenohymal tumor, 1he group's secretary e~ed in some propai)'!Dda for the nerve sheath concept, reiterating that hei!IOcytee could produce collagen and ether structures 1111uall;r considered mesodermal and shoving a. case of hie own which. Dr, Stout had classified as "a. rather t)'llioe.l neurUOlll:loma", Ini­tially he mde very little headwa.;r, However, eomB of the later oases in the current set were more persuasive and before the evening wae over, most changed their votes to neurilemmoma for No, S.. 1he final vote -neurilemmoma 5, hemngioma 1, neuroblaatom ( submitted) 1, All those actually present at the meeting felt that the leaion was benign,

FILE DIAGNOSIS: Sclerosed fibroid tumor. Oroas-1ndezs Byalinized neurilemmoma,

CA,SE NO, 6, A~ESSION NO, S98?, H, R. Irwin , H,D., and E, Conforth,M,D, Contributors,

.WS ,ANGELES ; Assigned diacuasor•a diagnoeia: Ganglioneuroma, 1he vote was unan1-

moua fer this diagnosis~

OAKT.A!lD: ~enign ganglioneuroma,

SA}! PIEOO: Genglioneurom 9 votea,

CEN'l'RAL V A IJ-EY 1 There was unanimity ( ? votee) tor ganglioneuroma on thia case, Dr.

Dee raieed the question aB to the nature of the othe.- elemonta in a eo-called ganglioneuroma,

FILE DIA<Di'OSIS: Ganglioneuroma,

-s-CASE NQ, 7, ACCESSION NO, 9119, Louiaa !Ceaebe;y, M,D., Contributor,

LOS ANGELES; Asai~ed diaouaaor1s di~oaiar Leio~oaafeoma,

~neral dilouaaion and alternate di~oeee: Neurogenic safeoma. Tri­chrome stain ahowa apparent fibrils of emooth muscle type in some of the cella, The votlil vas unanimous for le1o~oearcoma of the thigh.

OtU.tHD: Malignant eohvannoma.

SAil DIEGO: Malignant achwannoma 9 votea,

qEBTR4L VtTJ.EY;

No, 7 drew five votea for achwannoma and 2 for neurofibroaafeoma. It was felt that this difference of opinion was essentially dialectical and the group bad noth·iD.4!: to add on the eohwann oell vs. fibroblast dialectioa.

FILE DIAGNOSIS; Halignant schwannoma, erose-index: Leiomyosarcoma,

CA.5Pl NO, 8, ACCESSION NO, 9)60, C. B, Courville, M,D., Contributor,

WS ANGELES; Assigned disouaaor 'a dia~oah: Ependymoma,

General diaouaaion and alternate diagnoaee: (1) Chromophobe adenoma of pi tui ta17, ;papillary type. (2) Chromophobe carcinoma of pituitary. The votea Chromophobe adenoma 7. tumor of glioma group 2 votes, QAY,e!D:

Chromophobe adenoma of pituitat7.

S.AN DIEGO; Epen41moma 7 votes, chromophobe adenoma of pituitary, 2 votes,

CEHTRAL VALLEY : This was oonaidared. to repreaent a aella.r tumor eroding into tile

ainua. Attention was invited to a. recent report by one of the group of a similar experience with a tumor of rather similar appearance ( Ref,l,Caee 4). 'l'hia oaee waa called an epend3'moma by four of the group, 'lhe other three voted for· anaplastic pituitary adenoma, pointing out that the apparent ~11-lary structure could be duplicated in certain portions of the reference case, while other areas showed solid tumor. It was euggested tba.t tbie particular differential dia.gJloatic problem was an old one and that here again the differ­ence of opinion vae largely dia.leotioal.

F·ILE DIAGNOSIS: CbroiDOphobe adenoma, Crosa-index: Epend;yiDC)~~~a.,

-6-

C4SE NO, 9. ACCESSION NO, 796J, DorothT ~tter, M,D, , Contributor,

UlS ANGELES; Allaigned diacuesor 1a diagnosil: Neurogenic aarcoma,

General diacuaaion and alternate diagncaea: There ie a high inoidenoe of this type o! aa rcoma in vonRecklinghauaen •a diaeaae, ~a unueual mo.esive­neaa of the growth in thie caaa was noted, 'Dle vote; Neurogenic sarcoma on the baaia of vonl!eckl ingbaueen•a diaea.ae - unanimoue,

QAU,AND; Malignant achwannoma 8, malignant tumor unclaaaified a.

SAN DIEGO: Qenglioneuroblaatoma 9 votea ,

gcyTRAL VAI.T.!J : The aubmitted vote for -thia case was for aarooma ( ?rbabdo ), All au

melllbara present at the maetin& agreed that thia waa a tlli!IOr ahoVi.nc both nerve trunk elementa and pngl.ion cella and that it could be called either malignant echwannomn with j!allglion cella or i!:!Ulclicneuroaarcoma, depending on one's position in the Pential~Stout controversy, ~e adherent• of the echwannian view found it relat1veJ.7 simple to conceive of a line of achwann cella reverting to aomething that would produce aomething reaembliug PDti" lion oelle. On the other hand a tumor co~ad of sanglion cells and tibro­blaata would be a very miXed tumor indeed, ~~ qll8ation wae raiaad aa to 'lhether the tumor might poaeibl;r have arisen vithin the spinal canal and whether the paral;raia tor which the patient was originally admitted to the Rancho, could be due to praaeure rather than polio, However, it aeemed per­haps mora likely that the contributor had establiahed the diagnosis of old poliomyelitis at autopsy and that the tumor within the canal was l ate exten­sion,

FlliE DIAGHOSIS: Neurogenic sarcoma on the bash of vonReokl1Df!llaueen 1a dheaae,

CASE :00, 10, ACCESSION NO , 9161 , E, H. Butt, M,D,. Contributor,

lOS Al!GELES; Aaaigned diecuasor'e diagnoaia: Neuro!ibromatoaia, vonReckltnghau­

aen1a diaaase, The vote waa unanimoua tor thia diagnosis,

oep.eup; Benign neuro!ibromatoaia,

SJUl DIEGO; Neurofibroma, 9 votes,

cmJTRAL Vti.TFf: ~ere was unanimoue vote for malignant vonRecklinghauaen 1e tumor on

thie caee. Dr, Miller drew attention to the very variegated pattern with

continued - ·

-7-

C&&e Ho. 10, Acoeaaion No, 9161 - continued.

BOUle atructurea actually resembling normal narY .. in appearance. The eeore­tary commented that although generally a warm advocate of the aohwann cell vs, the perineural fibroblast in the genesis of peripheral nerve tumors, be is totally contused on the relation of neureotodermal and meaelleh~tous elements in vonReoklin&baueen's disease.

FILE DIAGNOSIS: Neurofibrome.toaie, vonReokli.Ddlauaen 1e diaaaee,

OA$E NO , 11, ACCESSION NO , ']448, Seymour B. Silverman , M.D., Contributor,

IDS ANGELES : A.Beigned diacuaeor's diagnosis: Ependymoma., Grade I (epithelial type), The vote vae unanimous for this diagnoait,

OAKLAND: Ependymoma, UI18Jiimoua.

SAN DIEGO; Epend;rmome., 9 votes.

OEN '1'RAL VALLEY : 1:he vote was unanimous for epithelial epeneymoma., The reaemblance to

thyroid tissue was noted.

FILE DIAGNOSIS: Ependymoma, Grads I ( epithelial type),

OASE NO, 12, ACCESSION NO . 9485, seymour B, Silverman, M,D, ,Contributor,

WS ANGELES: An1gned diacuasor'a diagnosis: Neurilemmoma of neck, The vote was

unanimous for this d1agnosi8a

SAN DIEGO: NeurUenmom 9 votea.

QJU.Alm;

Neurile11111oma , unanimous •

OEYTRAL V.ALLEY: Neurilemmoma., 7 votes,

J'ILE DIAGNOSIS: Neur1lemmome. of neck,

Al~a~ ?. RrOVft. M.D.Secreta. •