4
InMemoriam
1’RIM:IKY
NEOPLASMS OF THE A
REPORT OF FIVE
P LEU RA
CASES*
P A U L KLEMPERER, M.D. AND
COLEMAN B. RABIN, h1.D. NEW
YORK
Although primary pleural neoplasms are classed among the rarer types of tumors, their importance has been recognized in a rather extensive literature. Their histogenesis and their classification are still subjects of controversy. A study of the entire group of pleural tumors permits a classification which appears to be of value, not only theoretically, but also from a practical standpoint, for the recent advancement in thoracic surgery has made the successful removal of some of these growths possible. Macroscopically, the tuinors may be sharply divided into two main groups. The first consists of those primarily localized in one part of the pleura. The second consists of those of a diffuse nature, involving the entire pleura and usually ensheathing the lung in tumor tissue. The latter group is niainly of academic interest ; it forms the subject of the second part of this paper. LOCALIZED
TUMORS
O F T H E PLEURA
Localized tumors of the pleura may involve the parietal or the visceral layer. They comprise many histologic types and benign and malignant forms. The entire group is possessed of a common characteristic : they originate from the tissues beneath the superficial lining cells, in contradistinction to the diffuse form of pleural tumors, which probably arise from the surface lining. Tumors arising from beneath the parietal pleura of the wall of the chest vary greatly in their histologic structure because of the number of different structures that are present in this region in addition to the subserous areolar tissue. The fascia of the intercostal muscles, the nerve sheaths and the subpleural fat may also be the origin of a localized neoplasm. Malignant connective tissue tumors in this location have been described by Blumenau,l Israel-Rosenthal (second case) ,s -___-
* Submitted for
publication, Sept. 19, 1930. the Laboratories of Mount Sinai Hospital. 1. Blumenau, M. B . : Prirnares rkom der Pleura, Deutsche med. Wchnschr. 22:570. 1896. 2. Leube, W. : Spezielle Diagnose der inneren Krankheiten, Leipzig, F. C. W. Vogel, 1891, vol. 1, p. 166. 3. Israel-Rosenthal : Beitra zur Klinik der primaren Pleura Sarkome, Nord. med. Ark., 1900, vol. 7; cited ’ Virchows Jahresbericht 352:266, 1900.
* From
InMemoriam Kaufmann and Hofmokl.5 They were all large. In Hofmokl's case, the neoplasm weighed 7 pounds (3.2 Kg.). The tumors were described as round cell sarcoma, spindle cell sarcoma and angiosarcoma. They invaded the wall of the chest and metastasized to the visceral pleura, to the mediastinal lymph nodes and occasionally to the abdominal organs. Pallasse and Roubier (case 1 6, reported a lipomyxosarcoma originating from the subpleural fat over the diaphragm, and Barbier and Molland ' described a malignant fatty tumor arising from beneath the mediastinal pleura. Jacobaeus and Key and Sabrazes and Muratet reported similar tumors originating from the fat tissue beneath the wall of the chest. Benign connective tissue tumors in this location were described by Jacobaeus and Key (cases 2, 3 and 4).8 Neurosarconias originating from the intercostal nerves were first described by Grawitz,lo who mentioned five cases from his experience. I n one of these cases metastases developed. Banse," Kobilinsky l2 and Schmidt (second case) l3 described similar cases. Stewart and Adami l4 described a sarcoma beneath the costal pleura in which the intercostohumeral nerve was embedded. The tumor was encapsulated, but had eroded the cartilages of the ribs. On the other hand, the tumors reported arising from the subserous layers of the visceral pleura were generally not of an invasive character. A number of small growths, fibromas, leiomyomas, lipomas and chon4. Kaufmann, E. : Spezielle pathologische Anatomie, Berlin, W. de Gruyter & Company, 1922, vol. 1, p. 385. 5. Hofmokl: Endothelsarkom der rechten Pleura, Arch. f. Kinderh. 7:81, 1885. 6. Pallasse, E.,and Roubier, C.: Les tumeurs primitives de la plsvre, Ann. de mCd. 3:243, 1916. 7. Barbier, J., and Molland, H.: Un cas de tumeur maligne mediastins pleurale avec I'aspect histologique de lipo-sarcome, Lyon mkd. 188:623, 1926. 8. Jacobaeus, H. C., and Key, E.: Some Experiences with Intrathoracic Tumors, Their Diagnosis and Their Operative Treatment, Acta chir. Scandinav. 53: 573, 1920-1921. 9. Sabrazes, J., and Muratet, L. : Myxome lipomateaux, intra-thoracique, Arch. de mCd. exper. et d'anat. path. 21:580, 1909. 10. Grawitz, P. : Demonstration einer neuen Gruppe intrathorakaler Tumoren, Deutsche med. Wchnschr. 34:1123, 1908. 11. Banse : Ueber intrathoracische Fibrome, Neurome und Fibrosarkome, Inaug. Diss., Greifswald, 1908. 12. Kobilinsky : Ueber primare Sarkome in der Lunge, Inaug. Diss., Greifswald, 1904. 13. Schmidt, W. : Ueber Fibrome der Lungenpleura, Inaug. Diss., Greifswald, 1903. 14. Stewart;J., and Adami, J. G.: Case of Primary Angiosarcoma of Upper Portion of Left Pleura, Montreal M. J. 22:1909, 1893-1894.
5
6
InMemoriam dronias in this location, found accidentally at postniorteni examination, have been described in the literature. They will not be discussed in this paper. By far the most interesting and important group of localized subpleural connective tissue neoplasms consists of the so-called giant sarcomas of the visceral pleura. Their pathologic interest lies in the fact that the tumors described in the literature did not metastasize or infiltrate, in spite of the microscopic picture of sarcoma. Clinically, they are of importance because, if diagnosed early enough, they may lie removed, and I)ecause, if neglected, they cause death from disturbances in circulation due to the extreme proportions to which they grow. Sixteen cases corresponding to this type have been described in the literature I)y : Ilorendorf ,15 Schneider,'" Mehrclorf ,Ii Brauii,'* Kauf maim,' Nevinney.'" Ricard.'" Quincke and Garre,*' Henke,** Israelliosenthal (case 1) ,:+ Kidd and Hahershon.'3 Schmidt (case 1) ,I8 Kahler and Eppinger,2* Podack (case 3) *23 Sala 2'i and Pallasse and Rouliier (cases 2 and 3)." The tumors reported evidently grew very slowly and were present for many years hefore they gave rise to symptoms. By this time they were very large. The larger ones, in each case, practically filled one side of the thoracic cavity, displacing the heart ant1 coni])ressing the 15. Doreiidorf. H.: Demoiistratioii eiiier grosseii Pleuratuiiiors, Deutsche med. 1Vchnschr. 40:225, 1914. 16. Schiieider, J. : Ein aiiatoniisch uiid Itliiiisch uinschriel)eiier T y p ~ ides ~ Pleurasarkams, Virchaws Arch. f. path. Aiiat. 252:706, 1924. 17. JIehrdorf, R.: Fihrosarcoma mysomatoides pleurae permagnum. Beitrag zur Keiintnis der priinareii Pleuratuiuoreii. Virchons .4rch. f. path. Aiiat. 193:YL 1008. 18. Braun. H. : 1)emanstratioii cines Tuinors der Pleura, Verhandl. d. deutsch. Gesellsch. 87: 162. 1008. 19. Sevinney, H. : Beitrag xur Casuistik der "Expaiisiv wachsenclen Pleurarieseiisarkome." Mitt. a. d. Grenzgeh. d. \led. LI. Chir. 40:277. 1927-1928. 20. Ricard. \r. : Volumiiieux sarcome iiitra-thoracique d'origine pleurale, Bull. rt inem. Soc. de chir. de Paris 34:804. 1908. 21. Quiiicke and Carre : Luiigeiichirurgie. ed. -3, Jeiia, Gustav Fischer, 1911, 11. 193. 2-7. Henke. F.: llikroskopische Geschwulstdiagiiostik, Jeiia. Gustav Fischer. 1Y06, p. 238. 13. Kidd. P., and Hahershon, S. H.: Primary Nyxo-Sarcoma of the Pleura, Tr. Path. SOC.London 49:15, 1898. 24. I
InMemoriam
1’RIM:IKY
NEOPLASMS OF THE A
REPORT OF FIVE
P LEU RA
CASES*
P A U L KLEMPERER, M.D. AND
COLEMAN B. RABIN, h1.D. NEW
YORK
Although primary pleural neoplasms are classed among the rarer types of tumors, their importance has been recognized in a rather extensive literature. Their histogenesis and their classification are still subjects of controversy. A study of the entire group of pleural tumors permits a classification which appears to be of value, not only theoretically, but also from a practical standpoint, for the recent advancement in thoracic surgery has made the successful removal of some of these growths possible. Macroscopically, the tuinors may be sharply divided into two main groups. The first consists of those primarily localized in one part of the pleura. The second consists of those of a diffuse nature, involving the entire pleura and usually ensheathing the lung in tumor tissue. The latter group is niainly of academic interest ; it forms the subject of the second part of this paper. LOCALIZED
TUMORS
O F T H E PLEURA
Localized tumors of the pleura may involve the parietal or the visceral layer. They comprise many histologic types and benign and malignant forms. The entire group is possessed of a common characteristic : they originate from the tissues beneath the superficial lining cells, in contradistinction to the diffuse form of pleural tumors, which probably arise from the surface lining. Tumors arising from beneath the parietal pleura of the wall of the chest vary greatly in their histologic structure because of the number of different structures that are present in this region in addition to the subserous areolar tissue. The fascia of the intercostal muscles, the nerve sheaths and the subpleural fat may also be the origin of a localized neoplasm. Malignant connective tissue tumors in this location have been described by Blumenau,l Israel-Rosenthal (second case) ,s -___-
* Submitted for
publication, Sept. 19, 1930. the Laboratories of Mount Sinai Hospital. 1. Blumenau, M. B . : Prirnares rkom der Pleura, Deutsche med. Wchnschr. 22:570. 1896. 2. Leube, W. : Spezielle Diagnose der inneren Krankheiten, Leipzig, F. C. W. Vogel, 1891, vol. 1, p. 166. 3. Israel-Rosenthal : Beitra zur Klinik der primaren Pleura Sarkome, Nord. med. Ark., 1900, vol. 7; cited ’ Virchows Jahresbericht 352:266, 1900.
* From
InMemoriam Kaufmann and Hofmokl.5 They were all large. In Hofmokl's case, the neoplasm weighed 7 pounds (3.2 Kg.). The tumors were described as round cell sarcoma, spindle cell sarcoma and angiosarcoma. They invaded the wall of the chest and metastasized to the visceral pleura, to the mediastinal lymph nodes and occasionally to the abdominal organs. Pallasse and Roubier (case 1 6, reported a lipomyxosarcoma originating from the subpleural fat over the diaphragm, and Barbier and Molland ' described a malignant fatty tumor arising from beneath the mediastinal pleura. Jacobaeus and Key and Sabrazes and Muratet reported similar tumors originating from the fat tissue beneath the wall of the chest. Benign connective tissue tumors in this location were described by Jacobaeus and Key (cases 2, 3 and 4).8 Neurosarconias originating from the intercostal nerves were first described by Grawitz,lo who mentioned five cases from his experience. I n one of these cases metastases developed. Banse," Kobilinsky l2 and Schmidt (second case) l3 described similar cases. Stewart and Adami l4 described a sarcoma beneath the costal pleura in which the intercostohumeral nerve was embedded. The tumor was encapsulated, but had eroded the cartilages of the ribs. On the other hand, the tumors reported arising from the subserous layers of the visceral pleura were generally not of an invasive character. A number of small growths, fibromas, leiomyomas, lipomas and chon4. Kaufmann, E. : Spezielle pathologische Anatomie, Berlin, W. de Gruyter & Company, 1922, vol. 1, p. 385. 5. Hofmokl: Endothelsarkom der rechten Pleura, Arch. f. Kinderh. 7:81, 1885. 6. Pallasse, E.,and Roubier, C.: Les tumeurs primitives de la plsvre, Ann. de mCd. 3:243, 1916. 7. Barbier, J., and Molland, H.: Un cas de tumeur maligne mediastins pleurale avec I'aspect histologique de lipo-sarcome, Lyon mkd. 188:623, 1926. 8. Jacobaeus, H. C., and Key, E.: Some Experiences with Intrathoracic Tumors, Their Diagnosis and Their Operative Treatment, Acta chir. Scandinav. 53: 573, 1920-1921. 9. Sabrazes, J., and Muratet, L. : Myxome lipomateaux, intra-thoracique, Arch. de mCd. exper. et d'anat. path. 21:580, 1909. 10. Grawitz, P. : Demonstration einer neuen Gruppe intrathorakaler Tumoren, Deutsche med. Wchnschr. 34:1123, 1908. 11. Banse : Ueber intrathoracische Fibrome, Neurome und Fibrosarkome, Inaug. Diss., Greifswald, 1908. 12. Kobilinsky : Ueber primare Sarkome in der Lunge, Inaug. Diss., Greifswald, 1904. 13. Schmidt, W. : Ueber Fibrome der Lungenpleura, Inaug. Diss., Greifswald, 1903. 14. Stewart;J., and Adami, J. G.: Case of Primary Angiosarcoma of Upper Portion of Left Pleura, Montreal M. J. 22:1909, 1893-1894.
5
6
InMemoriam dronias in this location, found accidentally at postniorteni examination, have been described in the literature. They will not be discussed in this paper. By far the most interesting and important group of localized subpleural connective tissue neoplasms consists of the so-called giant sarcomas of the visceral pleura. Their pathologic interest lies in the fact that the tumors described in the literature did not metastasize or infiltrate, in spite of the microscopic picture of sarcoma. Clinically, they are of importance because, if diagnosed early enough, they may lie removed, and I)ecause, if neglected, they cause death from disturbances in circulation due to the extreme proportions to which they grow. Sixteen cases corresponding to this type have been described in the literature I)y : Ilorendorf ,15 Schneider,'" Mehrclorf ,Ii Brauii,'* Kauf maim,' Nevinney.'" Ricard.'" Quincke and Garre,*' Henke,** Israelliosenthal (case 1) ,:+ Kidd and Hahershon.'3 Schmidt (case 1) ,I8 Kahler and Eppinger,2* Podack (case 3) *23 Sala 2'i and Pallasse and Rouliier (cases 2 and 3)." The tumors reported evidently grew very slowly and were present for many years hefore they gave rise to symptoms. By this time they were very large. The larger ones, in each case, practically filled one side of the thoracic cavity, displacing the heart ant1 coni])ressing the 15. Doreiidorf. H.: Demoiistratioii eiiier grosseii Pleuratuiiiors, Deutsche med. 1Vchnschr. 40:225, 1914. 16. Schiieider, J. : Ein aiiatoniisch uiid Itliiiisch uinschriel)eiier T y p ~ ides ~ Pleurasarkams, Virchaws Arch. f. path. Aiiat. 252:706, 1924. 17. JIehrdorf, R.: Fihrosarcoma mysomatoides pleurae permagnum. Beitrag zur Keiintnis der priinareii Pleuratuiuoreii. Virchons .4rch. f. path. Aiiat. 193:YL 1008. 18. Braun. H. : 1)emanstratioii cines Tuinors der Pleura, Verhandl. d. deutsch. Gesellsch. 87: 162. 1008. 19. Sevinney, H. : Beitrag xur Casuistik der "Expaiisiv wachsenclen Pleurarieseiisarkome." Mitt. a. d. Grenzgeh. d. \led. LI. Chir. 40:277. 1927-1928. 20. Ricard. \r. : Volumiiieux sarcome iiitra-thoracique d'origine pleurale, Bull. rt inem. Soc. de chir. de Paris 34:804. 1908. 21. Quiiicke and Carre : Luiigeiichirurgie. ed. -3, Jeiia, Gustav Fischer, 1911, 11. 193. 2-7. Henke. F.: llikroskopische Geschwulstdiagiiostik, Jeiia. Gustav Fischer. 1Y06, p. 238. 13. Kidd. P., and Hahershon, S. H.: Primary Nyxo-Sarcoma of the Pleura, Tr. Path. SOC.London 49:15, 1898. 24. I
