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We report a 74-year-old woman with malignant mixed mullerian tumor and three women, aged 47, 58, and 76 years, with carcinosarcomas, all primary in the fallopian tube. The tumors grew predominantly intraluminally and were associated with hydrosalpinx. All four patients underwent salpingectomy. Two of them received radiation therapy; one died within 9 months because of the tumor and the second is well 2 years after diagnosis. Of the two women without additional therapy, one is alive with tumor 53 months postoperatively and the other is well 1 year after surgery. Available data suggest that these neoplasms are relatively radioresistant and that their prognosis correlates best with local invasiveness.

The clinical and pathologic features of 53 endometrical stromal tumors were studied to determine which pathologic characteristics were related to the clinical behavior. Morphologically, stromal tumors were divided into 2 groups: 18 tumors with pushing margins (stromal nodules) and 35 tumors with infiltrating margins (endolymphatic stromal myosis or stromal sarcoma). Stromal nodules, which were expansile, noninfiltrating lesions composed of cells similar to those found in normal endometrial stroma, were considered benign. The tumors with infiltrating margins were separated on the basis of mitotic activity. Patients with endolymphatic stromal myosis had 100% survival at 5 years and those with stromal sarcoma had 55% survival. The size of the primary tumor and presence of vein invasion showed a slight correlation with the patient's prognosis but no correlation was found with increasing degrees of cellular atypism. For patients whose disease was not controlled by hysterectomy and who had symptomatic extra-uterine tumor, x-ray irradiation appeared to be of benefit. The patients' symptoms and physical examination findings were not different from those of patients having other uterine tumors.

The clinical and pathologic findings of 203 patients with granulosa-theca tumors were analyzed to determine the features related to subsequent behavior of the tumor. The neoplasms were divided into three groups—granulosa tumors, mixed granulosa-theca tumors and thecomas. The actuarial survival rates of patients with granulosa tumors and mixed granulosa-theca tumors were nearly identical—both 97% at 5 years and 93% at 10 years. Only one of the 106 patients with a thecoma died of tumor, the other lesions being clinically and histologically benign. Capsular invasion and lymphatic invasion by the neoplasm were features associated with persistence of the tumor but the type of treatment, the degree of cellular atypism and mitotic activity were not. Unilateral oophorectomy is adequate therapy for granulosa-theca tumors confined to the ovary if biopsy and frozen-section examination are done on any suspicious lesion of the opposite ovary or other pelvic structure.

The clinical and pathologic findings in 94 patients with cystosarcoma phyllodes were studied to determine which pathologic characteristics were related to clinical behavior. The neoplasm recurred in 28 patients and 15 patients (17%) died of metastatic cystosarcoma. Most recurrences occurred within 2 years of initial surgery and all patients who died of cystosarcoma did so within 6 years. No tumor less than 4 cm in diameter or having fewer than 3 mitotic figures per 10 hpf in the areas of greatest mitotic activity proved fatal. Other microscopic features associated with a low risk of recurrence or of death were pushing margins (one death in 39 examples) and minimal cytologic atypism of the stromal cells (two deaths in 30 examples). No one feature was wholly reliable and a clearcut separation of benign from malignant tumors could not be made. Although axillary lymph nodes were enlarged in 17% of patients, metastasis to them occurred in not more than three instances (one histologically proved) and therefore radical mastectomy or routine axillary lymph node dissection is not worthwhile. Wide local excision for small cystosarcomas and simple mastectomy for larger ones is recommended. In addition, low axillary dissection should be considered in patients having clinically enlarged axillary lymph nodes and tumors larger than 4 cm if there is marked atypism of stromal cells or high mitotic activity, as determined by microscopic evaluation of the cystosarcoma.

The clinical and pathologic findings in 21 patients with adenoid cystic carcinoma of the breast are presented. Nineteen of the 21 patients were living and well after treatment. Two patients died of unrelated causes. Local recurrence appeared in only 2 patients, 3 and 7 years following simple excision, but they were free of disease 9 and 14 years after subsequent mastectomy. No clinical or pathologic evidence of lymph node or distant metastasis was found in any of the patients. For these reasons, simple mastectomy is advocated as preferred treatment for adenoid cystic carcinoma, unless the tumor is particularly large or there are enlarged axillary lymph nodes. The favorable prognosis of patients with adenoid cystic carcinoma of the breast is in sharp contrast to that of patients with histologically identical tumors in other sites. Possible explanations for this striking difference in behavior are discussed.

Vascular lesions in 21 women who died of thrombosis while taking various oral contraceptives and in 21 women who died of thrombosis but who had not taken the pill were examined. Routine histologic sections were available and 7 other special stains were prepared from tissues fixed in formalin. Three types of lesions developed in the pill group. First three-layered thrombi with underlying structural changes were found in 19 cases consisting of an organized revascularized basal layer with accumulated collagen and in some cases macrophages; a zone of fibrin with ingrown fibroblasts between and an unorganized laminated thrombus above. The underlying structures were thickened disrupted and filled with acid mucopolysaccharide. The second type of lesion present in smaller pulmonary vessels in 4 cases was proliferation of the endothelium and intima into a network of papillary projections. The third type of lesion was found in only one case: nodular thickening of the intima media and adventia of the pulmonary artery. These women all suffered from locally formed thrombi which developed over a period of days or weeks indicating primary changes in the blood vessels rather than emboli as the cause of death.

Men with mammary carcinoma have a worse prognosis than do women, even after noncancer deaths are excluded. This can be explained partly on the basis of the high proportion of lesions that lie beneath the nipple area (78%), as centrally located lesions have a greater incidence of metastasis to internal mammary lymph nodes with its consequent adverse effect on patient survival. The central location and the absence of significant encompassing breast tissue also allow small mammary cancers of men to involve the pectoral fascia and the dermal and subareolar lymphatic channels simultaneously. On the basis of size, smaller mammary cancers had only a slightly greater frequency of axillary metastasis in men than women but had considerably greater lethality, presumably because of higher frequency of internal mammary lymph node metastasis.

135 cases of carcinoma of the breast in women under 30 years (4 were 22 years or younger) were on file at the Armed Forces Institute of Pathology in Washington D.C. The gross characteristics of the carcinomas were the same as those in older women with the same types of cancer. The percentages of patients with and without axillary metastasis still well at last contact were 25% and 66%. The proportions of surviving patients with the 3 main types of tumors were infiltrating duct (70%) medullary (50%) and intraductal (11%). The prognosis was worse with larger tumor sizes. 61% 75% and 36% of patients with upper outer quadrant lesions lower outer quadrant lesions and inner quadrant or subareolar tumors were well at last contact. Only 4 (29%) of the 14 patients pregnant at tumor diagnosis were living and free of neoplasms at last contact. 10 diagnoses were at 5 months postpartum and 1 patient at diagnosis was 18 months postpartum but breast feeding. 54% of these 11 women were living and well at last contact. No relationship was found within the age limits of the study between age of patient and survival. Favorable factors influencing survival in women under 30 are the relative high proportion of favorable-type tumors and the relative rarity of deaths from unrelated causes. Unfavorable factors include the frequent association of the tumor with pregnancy or lactation a high incidence of axillary metastasis unusually poor survival in patients with 1 or 2 involved axillary lymph nodes and a high incidence of carcinoma of the opposite breast. Women under 30 appear to have a slightly poorer prognosis than do older women. Women taking oral contraceptives among the breast cancer patients were underrepresented (4-5 expected in 47 women from 1960-1964 1 found).

A series of nine tumors arising in the second portion of the duodenum has been presented. These tumors usually occurred in the fifth and sixth decades and clinically simulated peptic ulcer rather closely. Most of them were polypoid lesions not over 2.0 cm in diameter and were usually demonstrated on x-ray examination of the upper digestive tract. Histologic study invariably showed two elements to be present: one, a spindle cell component similar to the spindle cell portion of ganglioneuromas or neurofibromas; the second, and most often dominant element, nests of epithelioid cells indistinguishable from the Zellballen of nonchromaffin paragangliomas in more typical locations. Modified Bodian stains demonstrated a large number of neurites in the tumors and argyrophilia of many of the epithelioid cells similar to the findings reported in carotid body tumors and other paragangliomas. The histogenesis is considered, and our reasons for regarding these tumors as paragangliomas rather than ganglioneuromas or other suggested lesions are presented.

The clinical and pathologic findings of 31 patients with uterine carcinosarcoma are presented. Carcinosarcomas arose within the endometrium and all but 2 invaded the myometrium and lymphatic spaces. Tumor had spread beyond the uterus in 12 (39%) of patients at the time of initial therapy. None of 8 patients (26%) who were free of cancer at last contact had extra-uterine extension or metastasis. Because the patients with carcinosarcoma had a significantly better survival rate than did a similar group with mixed mesodermal tumors, the 2 types of neoplasms should be separated. The authors believe that carcinosarcomas arise both from multipotent neoplastic cells that have the capacity to form both epithelium and stroma and from multiple neoplastic cell types having fixed potencies. Origin from embryonal rests, primitive analagen, or collision tumors is rejected. Because the distribution of metastatic lesions of uterine carcinosarcomas is similar to that of endometrial carcinomas, surgical management should be similar. It is not clear whether irradiation has any value as treatment.

A clinical and pathologic analysis of 30 lipid cell tumors of the ovary shows that both adrenocortical-like and hilus-like cells are present in most instances and that attempts to separate them objectively into adrenal-like tumors, hilus cell tumors or stromal luteomas is often impossible. Inasmuch as there is no histogenetic basis for employing this terminology, such a separation is considered artificial and of no value in predicting either functional manifestations or clinical behavior. Therefore, lipid cell tumors are regarded as a specific entity and not a collection of different lesions. Lipid cell tumors are most often virilizing (77% of patients) and may be associated with Cushing's syndrome (10% of patients) or with evidence of estrogenic activity (23% of patients). Although these tumors usually are considered benign, six patients in this series died of recurrent or metastatic tumor. The clinically malignant lipid cell tumors tended to be larger than the benign ones, had involved contiguous pelvic structures at the time of operation in half of the cases, and occasionally exhibited sufficient cellular pleomorphism and mitotic activity to permit objective interpretation as malignant. On the basis of the authors' findings and the evidence available in the literature, the most likely origin of lipid cell tumors is from the specialized ovarian stromal cells within the medullary part of the ovaries.

The clinical and pathological features of 26 neoplasms derived from ovarian stroma of canine species were analysed. Three types were identified: (1) granulosa tumours, (2) neoplasms with a Sertoli pattern, and (3) a heterogeneous group regarded simply as nonspecific gonadal stromal tumours. All three types of neoplasm were found in mature dogs. Hyperoestrinising effects occurred in five animals (33 per cent.) of the granulosa group, three (50 per cent.) with Sertoli tumours and four (80 per cent.) of those with nonspecific gonadal stromal tumours. Granulosa tumours were clearly malignant, as three (20 per cent.) had spread beyond the ovary, in contrast to the neoplasms of the other two groups, none of which had metastasised. Tumours with a Sertoli pattern were closely related to granulosa tumours, as they were composed of cells similar to granulosa cells at the periphery of developing follicles and within some atretic follicles of the canine ovary. There were also overlapping patterns with granulosa tumours. Leydig cells and androgenic effects were absent. The neoplasms in this study were compared with tumours of other mammalian species from the standpoint of frequency, morphological pattern and behaviour.

This clinical and pathologic study of 24 vaginal polyps, 22 from adults and 2 from infants, was prompted by the need for recognition of a benign polypoid vaginal lesion which must be distinguished from sarcoma botryoides, rhabdomyosarcoma and mixed mesodermal tumor. Twelve of the 22 polyps from adults contained atypical cells within the stroma. Five of these patients were pregnant when the polyp was discovered. Follow-up showed that the polyps are benign and adequately treated by local excision. The polyps from the 2 newborn infants were present at birth and were characterized by diffuse edema but contained no atypical stromal cells. One of the polyps regressed after biopsy. The other was locally excised and did not recur. Maternal hormones are thought to induce the intra-uterine development of the polyps in infants. The criteria for distinguishing vaginal polyps from sarcoma botryoides, rhabdomyosarcoma and mixed mesodermal tumor are discussed.

Polypold vaginal lesions containing striated muscle characteristically give rise to a diagnosis of sarcoma botryoides with its consequent therapeutic and prognostic implications. This report describes the second patient in the American literature with a benign polypoid vaginal tumor containing striated muscle. The patient was an asymptomatic 50-year-old Caucasian woman with a 2-year history of a nonulcerated polypoid mass in the anterior third of the vagina. She has remained asymptomatic and without recurrence 6 months after local excision of the lesion. Histologically, there was an edematous stroma with rhabdomyoblasts having longitudinal myofibrils and conspicuous cross striations diffusely sprinkled among mature fibroblasts and unit fibrils of collagen. There was no mitotic activity or cellular atypia. Ultrastructural study disclosed that a majority of the rhabdomyoblasts were composed of well-organized sarcomeric units with the Z bands in register, reminiscent of normal striated muscle. Our studies indicate that the vaginal rhabdomyoma has distinctive histologic and clinical features which differentiate it from other polypoid vaginal lesions as well as from rhabdo-myomas of skeletal muscle.

In 13 patients, a distinctive type of atypical polypoid endocervical hyperplasia was found. To our knowledge, this type of lesion has not been previously recognized. Such lesions have been observed [by us] with increasing frequency during the past two years and are important because they are sufficiently disturbing histologically to raise the question of carcinoma. Thus far, this variety of hyperplasia has been found only in women taking oral progestins, usually for purposes of contraception. Despite their resemblance to adenocarcinoma, the available data point to a benign interpretation. Whether these lesions are more than coincidentally related to use of oral progestins is unknown, but the association is striking and requires experimental evaluation of a possible relationship.

Benjamin, Ivy, Taylor, Herbert, and Spindler, James: Orbital and conjuctival involvement in multiple myeloma. Report of a case. Am J Clin Pathol 63: 811-817, 1975. Orbital and conjunctival involvement in multiple myeloma are rare. In most reported cases of multiple myeloma with orbital involvement proptosis has been the initial manifestation that has led to diagnosis of the disease. Our case represents and example of terminal involvement of the orbit and conjunctiva, causing proptosis. The minimal conjunctival changes were the first indication of neoplastic proliferation of plasma cells in this location and, presumably, the orbit.

A patient with primary transitional cell carcinoma of the fallopian tube, primary endometrial adenocarcinoma, and primary endometrioid carcinoma of the ovary is reported. The clinical picture was similar to that of adenocarcinoma of the fallopian tube, but the mode of spread was somewhat different and more aggressive. The patient was treated with surgery and a combination of internal and external radiotherapy.

The clinical and pathological features of 21 ovarian germ cell tumours (14 dysgerminomas and 7 teratomas) from four mammalian species are presented. All the dysgerminomas were composed of a monophasic population of cells with a variable type of stromal response, depending upon the species, and 11 of the 14 were confined to the ovary. Only one dysgerminoma was associated with teratomatous elements. The teratomas were relatively solid, less cystic than those of women, and mature tissue predominated, although solid teratomas contained immature elements capable of metastasis. There were no examples of embryonal carcinoma or choriocarcinoma such as occur in women. From our observations and those of others, coupled with experimental data, it is concluded that germ cell tumours may be divided on the basis of their potential for differentiation. Those failing to express any potential for differentiation persist essentially unchanged as either dysgerminoma or seminoma. Other germ cell tumours have some potential for tissue differentiation. That potential may lead to a very restricted and immature differentiation, such as embryonal carcinoma or choriocarcinoma as in women. Beyond the primordial germ cell stage, germ cell tumours in other mammals primarily manifest somatic differentiation (teratomas). Among the tumours exhibiting differentiation, the clinical behaviour tends to parallel the degree of differentiation. At one end of the germ cell spectrum is the primitive and highly malignant embryonal carcinoma, and at the other is the benign adult cystic teratoma.