Sarcoma

“ The distinction between carcinoma and sarcoma cannot always be made during life, nor indeed, without a microscopical examination, after death. It is of importance chiefly with reference to prognosis after operation for removal of the organ. A more rapid growth, a greater tendency to invade other organs, and a more marked cachexia would speak in favor of carcinoma, while a tumor gradually attaining a very large size, and not spreading beyond the kidney and its immediate envelopes, is more likely to be a sarcoma. ”

“ In adults melanotic sarcoma is most common. It occurs between the ages of forty and sixty, and is almost always unilateral; and while it shows little tendency to invade the brain, the adjacent lymph glands are early infected, and death usually results from dissemination.
In all varieties of intra-orbital tumour exophthalmos is a prominent feature (Figs. 238, 239) , and when the protrusion of the eyeball is marked the lids become swollen, œdematous, and dusky. The eye is seldom pushed directly forward except when the tumour is growing in the optic nerve or its sheath. ”

“ In its growth, a sarcoma compresses and destroys neighbouring parts, surrounds vessels and nerves, and may lead to destruction of the skin, either by invading it, or more commonly by causing sloughing from pressure. Inflammatory and suppurative changes may take place as a result of pyogenic infection following upon sloughing of the overlying skin or upon an exploratory incision. Once the skin is broken the tumour fungates through the opening. Sarcomas vary in malignancy, especially as regards rapidity of growth and capacity for dissemination. ”

“ The sarcoma ta and carcinoma ta differ somewhat as regards the path of dissemination. The former are vascular tumours, well supplied with blood-vessels; consequently dissemination usually occurs by way of the blood-stream rather than by the lymphatic circulation, and the commonest site for the secondary deposits of sarcoma is the lung. The carcinoma ta are less vascular, and the tendency of the growth is to invade the small lymph channels, so that the first signs of metastases are to be looked for in the lymphatic glands ”

“ As in many other cases, the discovery of the influence of erysipelas on sarcomatous growths was by investigation founded upon accidental occurrences, to wit: Busch reported a case of multiple sarcoma of the face cured by an attack of facial erysipelas; Durante, a sarcoma of the neck; Biedert, an enormous round-celled sarcoma, including the mouth, nose, and pharynx; Bruns, a melanotic sarcoma of the breast; Gerster and Bull, each a recurrent sarcoma of the neck; all cured or disappeared with no return, after an erysipelatous attack. ”

“ Not only is this true of epithelial cells, but the connective tissue-cells of the supporting structure of cancerous growth, after repeated transplantation, may become so altered that a gradual evolution of apparently normal connective tissue into sarcomatous elements takes place, these giving rise to “mixed tumours.” The sarcomatous development may even completely outgrow the epithelial elements and so form and continue to grow as a pure sarcoma. ”

“ Sarcomata of the brain are common, as our table shows. In them the cell-elements predominate, both in the large- and small-celled variety. They are malignant and grow rapidly. The form known as alveolar sarcoma, which has a distinct stroma, is to be distinguished from the cancers ”

“ Interference with respiration may necessitate tracheotomy. When the patient has difficulty in taking food, recourse should be had to the use of the stomach-tube or to gastrostomy. The use of radium or of the X-rays appears to have a restraining influence on the disease in the glands, but has not proved curative.
Sarcoma of the tongue is rare, and is sometimes met with in children. The round-cell type is the most common; it grows rapidly, and tends to ulcerate and fungate, pain becoming severe when the growth has broken down. ”

“ Before metastasis has taken place the differential diagnosis between sarcoma and benign fibroid tumor can be 228 made only by microscopic examination of the discharge or of curetted or excised portions of tissue. The duration of sarcoma of the uterus is about three years.
Sarcoma may occur at almost any age. Hysterectomy has been performed for this disease in a girl of thirteen. Several cases have been reported under twenty years of age. The most usual period is about the time of the menopause, in the decade from forty to fifty. ”

“ In central sarcoma pain is the first symptom, and it is usually constant, dull, and aching; is not obviously increased by use of the limb, but is often worse at night. Swelling occurs late, and is due to expansion of the bone; it is fusiform or globular, and is at first densely hard, but in time there may be parchment-like or egg-shell crackling from yielding of the thin shell. The swelling may pulsate, and a bruit may be heard over it. In advanced cases it may be impossible to differentiate between a periosteal and a central tumour, either clinically or after the specimen has been laid open. ”

“ Miliary granulations have been seen on the valves.
Cancer and sarcoma rarely are primary, and are not often met with as secondary growths. Sometimes a mediastinal sarcoma penetrates along the veins and involves the auricle, with or without great involvement of the pericardium. The secondary tumors may be single or multiple. In a case of cancer of the uterus I found a large mass in the wall of the right ventricle, involving also the anterior segment of the tricuspid, and partially blocking the orifice. The surface was eroded, and the pulmonary arteries contained numerous cancerous emboli. ”

“ The malignant neuroma is a sarcoma growing from the sheath of a nerve. It has the same characters and clinical features as the innocent variety, only it grows more rapidly, and by destroying the nerve fibres causes motor symptoms—jerkings followed by paralysis. The sarcoma tends to spread along the lymph spaces in the long axis of the nerve, as well as to implicate the surrounding tissues, and it is liable to give rise to secondary growths. The malignant neuroma is met with chiefly in the sciatic and other large nerves of the limbs. ”

“ Carcinoma and sarcoma sometimes grow from the muco-periosteum in the region of the ethmoid. They tend to invade adjacent parts, giving rise to hæmorrhage and symptoms of nasal obstruction, and as they increase in size they may cause considerable deformity of the face. If diagnosed early, an attempt should be made to remove the growth. ”

“ The shaft is increased in girth as a result of its being surrounded by a new case of bone. The resemblance to sarcoma may be very close, but the swelling is not as defined as in sarcoma, nor does it ever assume the characteristic "leg of mutton" shape. In both diseases there is a tendency to pathological fracture. It is difficult also in the absence of skiagrams to differentiate the condition from syphilitic and from tuberculous disease. If the diagnosis is not established after examination with the X-rays, an exploratory incision should be made; if dead bone is found, it is removed. ”

“ Paleness, weakness, and loss of strength often attend the development of cancer, but many do not exhibit these symptoms.
Sarcoma is often seen in the young and well nourished; it grows very rapidly; the skin is usually not adherent to the tumor; there is generally no pain; heredity has no relation to its development; paleness is absent in many cases; the favorite seats are the muscle, bone, glands of neck, brain, and many other localities; it is not nearly so common as cancer.
Cancer of the breast begins as a lump, occurring more often to the outside of the nipple, but may develop in any part. ”

“ True cancer or carcinoma of the kidney is not a common disease, and is said to have been found 12 times in 447 cases of cancer of various organs. It may be primary or secondary, and a description of the gross appearances would be essentially the same as that of the sarcoma. The tumor does not, however, usually attain so large a size, and the amount of degeneration of neighboring organs and of ulceration is greater. Calculi are often found in cancerous kidneys.
The SYMPTOMS produced by either sarcoma or carcinoma may be none at all for a time. ”

“ Sarcoma of the skin is a more or less malignant new growth, of rapid or slow progress, characterized by the appearance of single or multiple, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors, of size varying from that of a shot to a hazelnut or larger. As a rule the growths are smooth, firm and elastic, somewhat painful upon pressure, and exhibit a tendency to ulcerate. ”

“ In the retro-peritoneum, for example, true lympho-sarcoma is not uncommon, forming large tumors which may press forward the viscera and produce a very prominent mass in the abdomen. They are not uncommon in children, and with renal sarcomas make up three-fourths of the abdominal growths of early life. ”

“ Besides the sarcomata we find in young children frequently so-called mixed tumors, consisting of several kinds of tissue; in the kidney tumors for instance we may find side by side proliferating epithelial gland tissue, round cells resembling sarcoma, muscle and even bonelike tissue. In other organs also we find not rarely such mixed tumors to prevail among the cancers in children. Cancer of the female generative organs occurs in children not mainly in the uterus, as is the case in adults, but in the ovaries and in the vagina. ”

“ Woods. We [Pg 346] found that the tumor did extend from the antrum, into which I could bore my finger easily. Dr. O'Sullivan, Professor of Pathology in Trinity College, declared the growth to be a round-celled sarcoma. Of that there is no doubt. The tumor returned in a couple of months, and the patient then saw Dr. Semon, in London, who advised immediate removal. He returned home, and after a further delay he asked to have the operation performed. I did this in May last by the usual method. I found the tumor occupying the whole of the antrum. The base of the skull was everywhere infiltrated. ”

“ Sarcoma of the pancreas occurs with extreme rarity. It is impossible during life to distinguish it from carcinoma.
Tubercle of the gland is infrequently met with. Some pathologists deny its occurrence, and believe that the cases recorded as such are merely instances of caseous degeneration of the neighboring glands. When it does occur, it is always secondary, the primary disease being situated in the lungs or intestines. The alterations in the gland consist in the development of cheesy masses or of miliary granulations in the connective tissue between the acini. ”

“ Sarcoma, primitive or secondary, of the kidney is a somewhat rare occurrence, but most frequent in children. The whole kidney may be transformed into a mass occupying its place and somewhat resembling it in form, but many times exceeding it in bulk and weight. Such a tumor may largely distend the abdominal cavity and compress its contents. Upon section we often find a substance varying greatly in consistence, from almost fibrous hardness to cavities filled with grumous material broken down by fatty degeneration and often colored by hemorrhage. ”

“ Eoughly we may however classify the various cancers in those derived from epithelial tissue (for instance of the skin, stomach, uterus, the various glands) which we call carcinomata and those derived from proliferating connective tissue cells. Connective tissue in any part of the body may give rise to cancer. These connective tissue cancers are called sarcoma. The growth of a cancer exerts injurious influences on the organism as a whole. ”

“ Secondary nodules may appear near the primary tumor. The outer skin is not involved so soon as in cancer, nor does ulceration follow so rapidly. Sarcoma is about the most frequent and dangerous tumor that is found in cattle. It occurs in young animals, and is found on the serous membranes, in the glandular organs, and on the outer skin, especially of the neck and shoulders—in fact, in nearly every tissue and in almost every part of the body. This tumor is often found in places exposed to traumatisms and at seats of scars, or of irritations from pressure and inflammation. ”

“ Carcinoma is more common than sarcoma. It may take the form of squamous epithelioma or of medullary cancer, and may originate in the tonsil, in the groove between the tonsil and the tongue, or in the soft palate. By the time the patient seeks advice it has usually implicated the fauces, soft palate, and pharyngeal wall as well as the tonsil.
Males suffer more frequently than females. The disease may exist for a considerable time before giving rise to marked symptoms, and attention may first be drawn to it by pain and difficulty in swallowing, or by pain shooting towards the ear. ”

“ Under artificial propagation cancer maintains all the characters of the original tumours of the primary hosts. Carcinoma and sarcoma agree in possessing all the pathological and cellular features of malignant new growths. ”

“ Whether dependent on injury or not, the symptoms associated with sarcoma of the skull vary according to whether the tumour is extrinsic or intrinsic—whether, for instance, the growth develops in the inward direction and presses on the brain, or grows from the pericranium and is directed externally. Intrinsic tumours, with the exception of some local pain, œdema of tissues, and dilatation of superficial veins, give rise to symptoms closely resembling those observed in intracranial tumour formation. ”