352
THE INDIAN MEDICAL GAZETTE THYMOMA
By
B. P.
TRIBEDI,
m.b.
(Cal.),
d.b.
(Lond.),
f.n.i.
Tumours of the thymus gland are rare, and the study of these is of importance because, of the controversy about their pathology. Malignant tumours of the thymus are of interest not only on account of their rarity, but also because of the controversy regarding the histogenesis' of the gland (Crosby, 1932). Janeway (1920) urged the importance of early diagnosis and familiarity with the clinical course of these tumours, for in a large number of cases radium or x-ray therapy offered relief, even if not a prospect of cure. Roentgen examination is of the utmost diagnostic importance. The location 'and appearance of the shadow are characteristic. The pathology of a thymoma is still a matter of controversy and will remain so until histologists agree upon the normal constituents of the and Rahte, 1929). thymic parenchyma (Herriman ' Foot (1926) observed malignant thymomas are distinctly rare, less than a hundred having been described to date. A complete understanding of malignant thymic tumours will, of course, never be arrived at until we know more about the thymus and until the question of the aetiology of malignant tumours in general has been answered. In the meantime, we may assist investigators of both these questions by carefully studying and reporting every case of malignant thymoma '. In consideration of the above, it has been thought worth while to publish the two cases of thymoma that we have been able to collept since 1900 from the records of the Pathology Department of Calcutta Medical College. Case 1.?S. 'I., Mohammedan, male, aged 20 years, a fitter by occupation, was admitted in the .hospital for? (a) Difficulty in breathing?duration 7 days. (b) Swelling of the neck?the same duration. (c) Difficulty in swallowing?the same duration. History.?He fell down from a height of 10 feet, having slipped from the steps of a ladder, about two weeks prior to the admission. He felt pain immediately over the chest which gradually subsided. Then the above complaints appeared. X-ray report showed pleuro-mediastinal effusion in the left side and a diagnosis of hajmothorax was made. On aspiration, 20 c.cm. of blood-stained fluid were withdrawn from the left pleural cavity. He died suddenly two days after the aspiration after an acute attack of dyspnoea. The body was sent to the ^
morgue where, on post mortem, a huge noticed over the cardiac area completely hiding the heart, and it appeared that/the mass was composed of thickened pericardium) As a matter of fact the specimen was sent to mass
?
was
1944
to investigate the nature of the thickened, pericardium. On cutting the mass, the heart and pericardium were found to be perfectly normal and completely hidden by the tumour (figure 1, plate XVII). Histological examination showed the following features :? The general cell pattern was of small round cell type with a vesicular nucleus ; the cytoplasm showed slight acidophilic character. The intracellular substance was very scanty (figure 2, plate XVII). Quite a number of blocks were
us
Professor of Pathology and Chief Pathologist to the Medical Callege Hospitals, Calcutta, and Bacteriologist to the Government of Bengal
police
[Aug.,
studied
but
none
showed
puscles.
any
Hassall's
cor-
Case 2.?Sribairi, Hindu, male, aged 10, was admitted on 30th November, 1942, with difficulty in breathing for the last two months, which was gradually getting worse and worse. On examination, marked swellings of the whole of the face and neck, and slight swelling on the anterior chest wall, with engorged superficial veins, were noted. He had a feeble and rapid pulse, 138 per minute, and hurried respiration. He was found to be in acute distress. He died on the same day, and an autopsy was
performed. On opening
the chest cavity, a hard nodular in the anterior and middle mediastinum. The tumour was seen to infiltrate into the right lung (figure 3, plate XVII). The anterior wall of the pericardium was adherent to the tumour mass, but no infiltration into the pericardium was seen. There was no other significant finding anywhere, nor was there any other focus of. metastasis. "Histological examination showed the same characteristics as the previous one, viz, small lymphocytic type of cells with scanty intracellular substance and absence of Hassall's corpuscles. The metastatic tumour from the lung showed the same features as the original one. Some of the dissemination in the lung took place through the bronchial tree which was evident (figure 4, plate XVII). Discussion and comments.?Ewing (1931) classified the thymic tumours as follows :? mass was seen
of
(1) Lymphosarcoma
or
thymoma composed
diffuse growth of round polyhedral and giant cells. The chief source of this tumour is probably the reticulum cell, but lymphocytes are present in large numbers. (2) Carcinoma arising from the reticulum cells. To these may be added the very rare and somewhat questionable cases of spindle-cell or myxosarcoma. ' Crosby (1932) traced the history of the term Thymoma' and reviewed the opinion of various authors on the vexed question of the classification of the tumours of the thymus, and further observed that to understand the nature of the neoplastic diseases of the thymus, it is necessary to review briefly the and the histology of the thymus embryology 1 At about the second month of prenatal gland. life, the thymus which up to this time was an endodermal organ, begins to be infiltrated with a
MALIGNANT TUMOURS OF THE KIDNEY
Aug., 19441
lymphocytes. liferate
These
among, and
?f the
cells migrate into, proseparate the epithelial cells
It has been shown that the cell is a true small lymphocyte, and it may differentiate into granular lymphocytic cell or into plasma cells ; when animals are treated with x-ray, the differentiation is brought about. Some, however, believe that the endodermal cells (endodermal thymic reticulum) differentiate to form the so-called thymic cells '. Kettle (1925) is rather sceptical about the thymic origin of these-tumours. He prefers to mclude these tumours as mediastinal lymphosarcoma originating from the lymphoid tissue, as some of these tumours originate from the Posterior mediastinum. A comprehensive discussion in this subject entails a review of the embryology, histogenesis and pathology of the thymus gland which have been fully dealt with by Foot (1926), Jacobson (1923) and Symmers and Vance (1921). In the two cases reported above, the main characteristics are the same in both, i.e. the tumours were composed of small round cells with scanty intracellular substance. In none of these could we find any Hassall's corpuscles. It appears that the presence of Hassall's corpuscles Is not an essential feature of these tumours (Herriman and Rahte, 1929). With regard to the metastasis Crosby (1932) collected seventyeight cases of such lymphosarcomatous tumours, and showed that, although the neighbouring organs to the thymus are the usual sites of infiltration, general dissemination was also by no means uncommon. In our case 1, although the tumour was very large, no secondary foci could be found on post mortem. In case 2, the right lung was infiltrated. Besides the usual route of spread, some part of the spread must have taken place through the bronchioles (figure 4, plate XVII). This type of spread appears to be not yet reported.
thymus.
thymic
Summary and conclusion (1) Two cases of thymoma have been reported with metastasis through the bronchioles in one case.
(2) A short discussion as to the histogenesis of this type of rare neoplasm is given. REFERENCES
Crosby, Ewing,
E. H. (1932)
..
J. (1931)
..
Foot, N. C. (1926) Herriman, F. R.,
..
and
Rahte, W. E. (1929). V. C. (1923). H. H. (1920). E. H. (1925). Kettle,
Jacobson, Janeway,
Symmers, D., and Vance, B. M.
(1921).
Amer. J. Cancer, 16, 461. Neoplastic Diseases. W. B. Saunders Co., Philadelphia. Amer. J. Path., 2, 33. 5, 29. Ibid., Arch. Int. Med., 31, 847. Ann. Surg., 71, 460.
Pathology of Tumours. Lewis and
H.K.
Co., London. Arch. Int. Med., 28, 239.
:
KINI
353
THYMOMA
'8. 1 Pig,
i
ri
the of the 1.i Photograph photograph of hlrno-Co,e WpCa.e rseen be seen could be The The heart heart could doep, c?ncealed fioepiy1' mass tumour mass the tumour c?ncealed bv by the ' ?
^ig. 3
2. Photograph showing Photographshowing n?e heart has beenpushed hasbeen pushed heart the,]?ftf side and was seenpartly partly side and wasseen
t^OUr the 1 I i
nidden tumour. Kldenbvbv the thetumour.
:
B. P. TRIBEDI.
PAGE 352.
Fig. 2.?Case 1.
Photomicrograph of the sections from the tumour. Note Note uniform character of of the the cells with scanty intracellular substance.
section the section 2. Photomicrograph of the 4.?Case 2. Fig. Photomicrograph of Fig. 4.?Case from tumour cells cells within within the lung tissue showing from the lung tissue showing tumour the the lumen of lumen of
aa
bronchiole. bronchiole.
THE INDIAN MEDICAL GAZETTE THYMOMA
By
B. P.
TRIBEDI,
m.b.
(Cal.),
d.b.
(Lond.),
f.n.i.
Tumours of the thymus gland are rare, and the study of these is of importance because, of the controversy about their pathology. Malignant tumours of the thymus are of interest not only on account of their rarity, but also because of the controversy regarding the histogenesis' of the gland (Crosby, 1932). Janeway (1920) urged the importance of early diagnosis and familiarity with the clinical course of these tumours, for in a large number of cases radium or x-ray therapy offered relief, even if not a prospect of cure. Roentgen examination is of the utmost diagnostic importance. The location 'and appearance of the shadow are characteristic. The pathology of a thymoma is still a matter of controversy and will remain so until histologists agree upon the normal constituents of the and Rahte, 1929). thymic parenchyma (Herriman ' Foot (1926) observed malignant thymomas are distinctly rare, less than a hundred having been described to date. A complete understanding of malignant thymic tumours will, of course, never be arrived at until we know more about the thymus and until the question of the aetiology of malignant tumours in general has been answered. In the meantime, we may assist investigators of both these questions by carefully studying and reporting every case of malignant thymoma '. In consideration of the above, it has been thought worth while to publish the two cases of thymoma that we have been able to collept since 1900 from the records of the Pathology Department of Calcutta Medical College. Case 1.?S. 'I., Mohammedan, male, aged 20 years, a fitter by occupation, was admitted in the .hospital for? (a) Difficulty in breathing?duration 7 days. (b) Swelling of the neck?the same duration. (c) Difficulty in swallowing?the same duration. History.?He fell down from a height of 10 feet, having slipped from the steps of a ladder, about two weeks prior to the admission. He felt pain immediately over the chest which gradually subsided. Then the above complaints appeared. X-ray report showed pleuro-mediastinal effusion in the left side and a diagnosis of hajmothorax was made. On aspiration, 20 c.cm. of blood-stained fluid were withdrawn from the left pleural cavity. He died suddenly two days after the aspiration after an acute attack of dyspnoea. The body was sent to the ^
morgue where, on post mortem, a huge noticed over the cardiac area completely hiding the heart, and it appeared that/the mass was composed of thickened pericardium) As a matter of fact the specimen was sent to mass
?
was
1944
to investigate the nature of the thickened, pericardium. On cutting the mass, the heart and pericardium were found to be perfectly normal and completely hidden by the tumour (figure 1, plate XVII). Histological examination showed the following features :? The general cell pattern was of small round cell type with a vesicular nucleus ; the cytoplasm showed slight acidophilic character. The intracellular substance was very scanty (figure 2, plate XVII). Quite a number of blocks were
us
Professor of Pathology and Chief Pathologist to the Medical Callege Hospitals, Calcutta, and Bacteriologist to the Government of Bengal
police
[Aug.,
studied
but
none
showed
puscles.
any
Hassall's
cor-
Case 2.?Sribairi, Hindu, male, aged 10, was admitted on 30th November, 1942, with difficulty in breathing for the last two months, which was gradually getting worse and worse. On examination, marked swellings of the whole of the face and neck, and slight swelling on the anterior chest wall, with engorged superficial veins, were noted. He had a feeble and rapid pulse, 138 per minute, and hurried respiration. He was found to be in acute distress. He died on the same day, and an autopsy was
performed. On opening
the chest cavity, a hard nodular in the anterior and middle mediastinum. The tumour was seen to infiltrate into the right lung (figure 3, plate XVII). The anterior wall of the pericardium was adherent to the tumour mass, but no infiltration into the pericardium was seen. There was no other significant finding anywhere, nor was there any other focus of. metastasis. "Histological examination showed the same characteristics as the previous one, viz, small lymphocytic type of cells with scanty intracellular substance and absence of Hassall's corpuscles. The metastatic tumour from the lung showed the same features as the original one. Some of the dissemination in the lung took place through the bronchial tree which was evident (figure 4, plate XVII). Discussion and comments.?Ewing (1931) classified the thymic tumours as follows :? mass was seen
of
(1) Lymphosarcoma
or
thymoma composed
diffuse growth of round polyhedral and giant cells. The chief source of this tumour is probably the reticulum cell, but lymphocytes are present in large numbers. (2) Carcinoma arising from the reticulum cells. To these may be added the very rare and somewhat questionable cases of spindle-cell or myxosarcoma. ' Crosby (1932) traced the history of the term Thymoma' and reviewed the opinion of various authors on the vexed question of the classification of the tumours of the thymus, and further observed that to understand the nature of the neoplastic diseases of the thymus, it is necessary to review briefly the and the histology of the thymus embryology 1 At about the second month of prenatal gland. life, the thymus which up to this time was an endodermal organ, begins to be infiltrated with a
MALIGNANT TUMOURS OF THE KIDNEY
Aug., 19441
lymphocytes. liferate
These
among, and
?f the
cells migrate into, proseparate the epithelial cells
It has been shown that the cell is a true small lymphocyte, and it may differentiate into granular lymphocytic cell or into plasma cells ; when animals are treated with x-ray, the differentiation is brought about. Some, however, believe that the endodermal cells (endodermal thymic reticulum) differentiate to form the so-called thymic cells '. Kettle (1925) is rather sceptical about the thymic origin of these-tumours. He prefers to mclude these tumours as mediastinal lymphosarcoma originating from the lymphoid tissue, as some of these tumours originate from the Posterior mediastinum. A comprehensive discussion in this subject entails a review of the embryology, histogenesis and pathology of the thymus gland which have been fully dealt with by Foot (1926), Jacobson (1923) and Symmers and Vance (1921). In the two cases reported above, the main characteristics are the same in both, i.e. the tumours were composed of small round cells with scanty intracellular substance. In none of these could we find any Hassall's corpuscles. It appears that the presence of Hassall's corpuscles Is not an essential feature of these tumours (Herriman and Rahte, 1929). With regard to the metastasis Crosby (1932) collected seventyeight cases of such lymphosarcomatous tumours, and showed that, although the neighbouring organs to the thymus are the usual sites of infiltration, general dissemination was also by no means uncommon. In our case 1, although the tumour was very large, no secondary foci could be found on post mortem. In case 2, the right lung was infiltrated. Besides the usual route of spread, some part of the spread must have taken place through the bronchioles (figure 4, plate XVII). This type of spread appears to be not yet reported.
thymus.
thymic
Summary and conclusion (1) Two cases of thymoma have been reported with metastasis through the bronchioles in one case.
(2) A short discussion as to the histogenesis of this type of rare neoplasm is given. REFERENCES
Crosby, Ewing,
E. H. (1932)
..
J. (1931)
..
Foot, N. C. (1926) Herriman, F. R.,
..
and
Rahte, W. E. (1929). V. C. (1923). H. H. (1920). E. H. (1925). Kettle,
Jacobson, Janeway,
Symmers, D., and Vance, B. M.
(1921).
Amer. J. Cancer, 16, 461. Neoplastic Diseases. W. B. Saunders Co., Philadelphia. Amer. J. Path., 2, 33. 5, 29. Ibid., Arch. Int. Med., 31, 847. Ann. Surg., 71, 460.
Pathology of Tumours. Lewis and
H.K.
Co., London. Arch. Int. Med., 28, 239.
:
KINI
353
THYMOMA
'8. 1 Pig,
i
ri
the of the 1.i Photograph photograph of hlrno-Co,e WpCa.e rseen be seen could be The The heart heart could doep, c?ncealed fioepiy1' mass tumour mass the tumour c?ncealed bv by the ' ?
^ig. 3
2. Photograph showing Photographshowing n?e heart has beenpushed hasbeen pushed heart the,]?ftf side and was seenpartly partly side and wasseen
t^OUr the 1 I i
nidden tumour. Kldenbvbv the thetumour.
:
B. P. TRIBEDI.
PAGE 352.
Fig. 2.?Case 1.
Photomicrograph of the sections from the tumour. Note Note uniform character of of the the cells with scanty intracellular substance.
section the section 2. Photomicrograph of the 4.?Case 2. Fig. Photomicrograph of Fig. 4.?Case from tumour cells cells within within the lung tissue showing from the lung tissue showing tumour the the lumen of lumen of
aa
bronchiole. bronchiole.
