Clinico-Pathological Conference

Abstract

S. S. (Case H0251), a 43-year-old Jewish woman, was first admitted to the University Hospital in August 1941, complaining of pain in the right cheek and swelling of the right submaxillary and cervical lymph nodes of eight months' duration. During this illness anorexia and vomiting developed and the patient had lost 30 pounds of weight. For three months there had been a painless lump in the right breast, and for several weeks before admission she had experienced pain in the left shoulder and upper abdomen. The initial physical examination showed a pale, chronically ill female with mild exophthalmos. Careful oral study revealed the presence of soft masses in the right cheek and a possible bulging of the right alveolar ridge. The right breast contained a hard, irregular mass, measuring 5 × 7 cm., not definitely attached to skin or muscle, but adherent to the areola (Fig. 1A). There was a mass in the right axilla the size of a walnut. The left breast contained a smaller mass in the upper outer quadrant (Fig. 1B). There was one enlarged node in the right inguinal region. The liver and spleen were both slightly enlarged. Large masses were present in the lower abdomen, thought to be attached to the uterus. Results of all laboratory studies, including the blood count, were normal. Roentgenograms of the sinuses showed chronic disease of both antra with polypoid changes on the right side. Roentgenograms of the mandible and chest were noncontributory. A biopsy of the mass in the right breast and the right inguinal node was obtained. The patient was discharged to the out-patient department after four weeks, having shown slight improvement during hospitalization. In November 1941, three months after her first admission, the patient was readmitted to the hospital with the added complaints of rapid increase in the size of the abdomen, dyspnea, and cough. Her menstrual periods, which had been scanty for a year, had ceased altogether for the past two months. At this time, physical examination showed emaciation, two masses in the right breast and five smaller ones in the left, and an abdominal mass which had increased greatly in size since the previous admission. Pelvic examination showed an enlarged irregular uterus and at least one large mass distinct from the uterus, which was thought to be an ovarian tumor. Because of extreme discomfort, operation was advised and a bilateral salpingo-oophorectomy was performed in December 1941. This was followed by recurring ascites and diminishing serum protein. The patient failed rapidly and died in January 1942, twelve months after her first symptoms and five months after her first hospitalization. Dr. Lockwood: This is a very unusual case. The patient presented evidence of a chronic wasting disease with a mass in each breast, enlarged nodes in the right axilla, and an abdominal mass or masses, which increased rapidly in size a month before death.