CHOY: The Result of 740 Sections Diagnosed

INTRODUCTION

In the fall of 1929, the research department of this institution had decided to undertake another line of activity in the collection of data with the object in view of gaining evidence concerning some aspects of the occurrence of tumors among Koreans. A new work of tumor registry was began by distributing forms called 'The tumor registry sheet' which had been compiled for this purpose. Senders of surgical materials were asked, after filling blank space lines for detailed descriptions, to return these forms with the specimen which they wished to be diagnosed by us. The practical part of the work was referred to me and necessary cooperation and support of the work was requested from the staff of this institution and also from friends in mission hospitals through out Korea.
Since that time 3 years and more have elapsed and so this is a suitable time to make my report, whether satisfactory or not, on this worthy project, further it is a proper time for my report because I shall no longer be able to continue this work as I am about to undertake another branch of service within this institution. As to the value of this work I am too modest to emphasize the result as in the first place I am tabulating the result rather too early and also too hastely and secondly some of my diagnosis in this report may not be absolute when studied in more detail allowing plenty of time in each questionable cases. Taking these facts not into consideration for a moment, this report may furnish you with some glimpse of interest as this is the first and only work of its kind in this country, as in other institutions all the section diagnoses are undertaken in each department separately by its own personnel.
Some advantages and disadvantages of our system is a matter of another discussion which I wish to take up some other time. However, if there be any thing of value in present report, the credit is to be given to the research committee who have advanced the idea and devised the method on which I had merely to follow and also to those friends who have cooperated with us in this work ; both the staff of this institution and doctors in mission hospitals through out Korea.
The preliminary report of this work was already made in last K.M.M.A. meeting in the Spring of 1932 under the title of 'Report on 500 sections diagnosed.' The total number of sections diagnosed in our patho-histological service in the department of Clinical pathology during last three years far out numbers the figure in this report but all of those cases with either inadequate description of materials or unprovided with slips are indiscriminably discarded from this report. In preparing this report, a duplication of same diagnosis in different parts in same person is avoided by omitting secondary diagnosis if the original diagnosis is listed, for instance a general Fibromatosis or Lipomatosis is treated as one case and also in case where two tissue are sent in for diagnosis; one from thigh a primary skin cancer and another of its metastased inguinal lymph node, the former tissue alone has been picked up discarding the latter. The technic employed was ordinary paraffin method and stained with hematoxylin-eosin for routine procedure but also other necessary special stains for different purpose had been used. In emergency cases frozen sections were prepared and gave a tentative diagnosis but always followed by paraffin section for confirmative diagnosis.

I. CLASSIFICATION AS TO AGE AND SEX OF PATIENTS AND ACCORDING TO GROUP OF SENDERS

Of total 740 cases involved in this report, only 564 or 77% were mentioned of sex varieties and of these 359 or 63% were females while 205 or 37% were males; roughly speaking we had twice as many cases of the females than males which gives as a contradictory impression over our customary belief that the males are always apt to predominate in surgical interference and this fact is largely due to some divergence in physiology and anatomy of women concerned with reproductive organs.
As the age of patients 46% were mentioned; the youngest being 43 days old a case of teratoma in coccygeal region and the oldest was 76 years old, a man with carcinoma on skin. The scales of curve reached highest to those between 30 to 40 years of age being 100 cases or 13.5%, then between 20 to 30 being 92 cases or 12.4%, thence from 40 to 50 and 50 to 60, 10 to 20 declining respectively. To speak in short the occurance of tumor is more frequent or the surgical interference is increased during a period of life activity between 30 to 50 years of age with an average of 37 years old. As to a racial classification, the majority were Koreans but also there were 18 Americans, 3 Japanese, 3 British, 2 Chinese and 1 Manchurian all included into this report. Beside these there were a considerbale numbers of sections on domestical animals but they are not included. When this report of 740 are analysed according to senders they are as follows; 63% of materials were requested from within this institution and 37% from out-side. In this institution 341 cases or 46% of total materials were supplied from Surgery and 104 or 20% of cases from Gynecology, and the rest being 32 from Skin 28 from E.N.T. etc. In non-institutional series 79 from Pyung-yang which corresponds to about 10% of this report, 6% or 49 cases from Dr. Chisholm of Syun-chun, and 34 or 4.5% from Dr. Hollister of Mok-po and 32 cases from Dr. Rogers of Soon-chun and many other small numbers from 12 mission hospitals which is about a half of all the mission hospitals in Korea.

II. ANATOMICAL CLASSIFICATION OF MATERIALS

1. Gastro-intestinal tract
The materials pertaining to this system from lip to anus were 97 in all which is about 13% of this report and they are 23 cases in oral cavity 10 on stomach, 9 from small intestine, 41 from appendix, and 14 cases from large intestine including sigmoid and rectum.
2. Respiratory tract
Total 20 cases from nose to lung including antrum and pleura corresponds to 2.7% of this report.
3. Genito-Urinary system
Total 248 cases belong to this system and of these 204 or 83% of the materials are from female genitals while those from male being only 31 cases; and they are 78 from Ovary 16 from Tubes, 108 from vagina. In male organs 8 from testis, 22 cases from Penis, 1 from Prostate and in urinary tract 10 from Kidneys, 2 from Bladder and 1 Urethra.
4. Abdominal viscera
Tissues from abdominal cavities excluding mesenteric lymph node were recorded in 55 cases and of these 12 from Liver, 5 from Pancreas, and 27 cases from Omentum and peritoneal wall etc.
5. Lymphathic system
Total 73 cases are recorded corresponding roughly to 10% of this report. Of these 26 from Cervical node being 35% of this series and 32 from Mesenteric lymph node which is about 45%. The rest of them were 10 from Axilla 3 from Inguinal and 1 from Trochondreal regeons.
6. Secretory glands
In this category 48 cases corresponding to 5.4% of this report has been recorded; 11 from Parotid region, and 38 from breast tissues all but 1 from female breast.
7. Gland of Internal secretion
Of this group only Thyroid gland has been examined and they are 23 in all comprising about 3% of this report.
8. Skin
Total 149 sections are examined which correspond to 20% of present report and their distributions are as follow; 12 cases on scalp, 10 on neck, 5 on back, 15 on thigh, 3 on face, 6 on chest, 8 on bottuck, 6 on tibia or leg, 9 on abdomen, 3 on arm, 5 on fingers, 2 on foot, and still there were about 50 cases where no description of site had been made.
9. Bone and Joints
Total 16 cases being about 2.3% of this report and among which 4 were from joints and figure includes two eases of teratomata of Coccygeal regeon.
10. Nervous System
In this group all the orbital tumors of different description and also pathology on Blephra have been included and they were 10 in all.

III. PATHOLOGICAL CLASSIFICATION OF MATERIALS

An effort has been made to classify the data according to pathological diagnosis in each anatomical sphere of distribution.
1. In mouth
Papillomata had been diagnosed in 3 cases; 2 on lips, 1 on tongue and 1 clinically diagnosed papilloma of tongue had on histological examination turned out to be gumma in a thirteen years old girl. 3 fibromata 1 fibrosarcoma and 1 case of acanthoma all on gums, and also 3 cases of cancers, of the gum were denied on pathological ground. However, 1 case each of carcinoma and myo-sarcoma were found on tongue while 2 other suspected clinical cancer had been disproved. The rest of the lesion in this area were 7 tonsilitis, glossitis, and stomatitis.
2. Stomach
Of ten sections taken from stomach, except one ease of perforation supported by adhesion of peritoneum for which a clinical diagnosis of possible mass of gastric tumor had been made, they were all tumors and at same time all malignant in nature. 8 were medullary type of carcinomata and 1 scirrhous in tendency. The youngest age of patient was 24 years old our employee in X-ray department, who had been opened for a tumor in stomach after suffering from indigestion for three months and when a shadow of mass in stomach was evident. The tumor was about the size of an goose-egg, polypoidal in shape, very firm in consistency and it was diagnosed for a sarcoma on both gross and preliminary microscopical examination but later on a careful scrutiny it was found to be an early case of medullary carcinoma.
3. Intestine
Of the nine cases they were; 1 intussusception, 2 myo-fibromata, 1 fibro-sarcoma, 1 lymph-sarcoma, and also 1 case of adeno-fibroma on Caeco-illiac valve. Beside these 3 intestinal ulcers and 1 abscess are on record.
4. Appendix
In total 41 cases of appendical involvement corresponding about 5% of this report, 25 of them were acute appendicitis of which 10 were either gangrenous or suppurative and the rest of them were catarrhal mostly impacted with fecal material in the lumen. 16 of them were in chronic state of inflammation either atrophic or fibrosed. The age of patient is not characteristic but impressed to be more frequent between 30 to 50 years of age female being 9 out of 14 in recent cases.
5. Colon
5 cancers were found; 1 in sigmoid and 4 in rectum, 3 condylomata of anus and also 1 papilloma and 4 Tbc. fistula of anus are on record. Beside these there was a material sent from Wonsan on autopsy where a typhoid diagnosis was made.
6. Respiratory system
Of 20 materials 5 papillary cancers of anthrum, 1 case each of papilloma and myxoma and 5 fibromata from nasal cavity. 1 case of diphtheria of pharynx, 3 granulations from plastic pleurisy and 3 Tbc. empyema. 1 case of fatty embolism of lung was confirmed over the clinical view on a material from autopsy sent from Dr. Fletcher of Taiku. 2 other requests for tumor cells from lung in pleural effusion were negative.
7. Ovary
The total 78 diagnoses on this organ correspond to 39% of whole female Genito-urinary organ involved and also corresponds roughly to 10% of total sections examined and reported in this paper. Of these 5 were dermoid cyst, 19 follicular cysts, 23 adeno-cystomata, 2 cases of malignant papillary adeno-cystomata one with metastasis in subcutanea of abdominal wall. 8 cases of adeno-carcinomata, 5 sarcomata, and 3 fibromata, 3 other ovarian tumor were found to be Uterine fibromata. Beside these there were 2 cases of corpus haemorrhagica and the rest of them were either sub-acute and chronic ooveritis.
8. Fallopian tubes
3 clinical ectopic pregnancy were confirmed in only 1 case and other two were found to be adeno-carcinoma of Ovary, and a case of Endometriosis. But on the other hand 1 case of cylindrical tissue with clinical diagnosis of acute appendicitis with rupture was found to be really a case of ectopic pregnancy. 1 case of endometriosis, 12 salphingitis, of which 4 were acute with infiltration of lymphocytes and eosinophiles and a few plasma cells suspected to be gonnorrheal in nature while other 7 cases were chronic inflammation and another case was tubercular in origin.
9. Uterine tissues
10 clinical diagnosis of carcinomata were revealed to be 3 negative but on the other hand 2 cancers were established on other diagnosis. Among 3 diagnosed as hydatid moles was found to be 1 fibro-sarcoma. In 5 cases the miscarriage were confirmed but in other 4 cases the clinical view had been disproved but on the other hand 3 cases of miscarriage were discovered from other diagnosis. In chronic endometritis history of recent labour and possible placental remain, 7 were positive while 4 of them negative and on the latter group a cases of Tubercular adhesion was found, probably to uterine wall. 33 cases of myo-fibromata or fibroid of uterus were found and 13 polyps on cervix and also there were 2 cases of fibro-sarcomata and 1 myo-sarcoma. The remainder of the tissues were all inflammatory; cervicitis and endometritis.
10. Vagina
In 3 cases of vaginal involvement 1 was papilloma, 1 cancer of urethral regeon and another being ulcerative inflammation.
11. Testis
Of 8 testicular tissues there were 1 fibro-sarcoma, 5 tubercular epidermysis, 1 fibroma, on tunica, and 1 case of Gumma sent from Dr. Fletcher of Taiku.
12. Kidneys
2 cases of adeno-carcinomata, 1 nephroma, and 7 cases of tuburculosis of which only two cases were in females.
13. Penis and Prostate
Carcinomata were found 14 out of 22 cases belong to this organ, 4 papillomata on prepuce, and on three other inflammatory lesions 2 cases of chanquer had been noted but on the other hand one clinically diagnosed chanquer was proved to be carcinoma. There was only single case of prostate which was a case of carcinoma.
14. Liver
Among 12 cases pertaining to this organ 8 were carcinomata, 3 abscesses and 1 clinically suspected carcinoma was found to be a case of biliary type of cirrhosis.
15. Pancreas
2 cancers were confirmed, but one was found to be an adhesion of duodenal ulceration and 1 case of clinically diagnosed pancreatic cyst was found to be haemorrhagic necrosis of pancreas in a male of 65 years old.
16. Spleen
4 fibrosis of which one was suspected to be a case of Banti's splenomegaly but a case of clinical splenomegaly was found to be a case of multiple focal necrosis in a woman with a history of sepsis after recent delivery.
17. Peritoneum
Most of the specimens were sent in with diagnosis of ascites and they were; 1 case of sarcoma of pelvis was found to be tuberculoma adhering to right fallopian tube, 10 tuberculosis, 8 carcinomata and 1 of two sarcomata of peritoneal wall was found to be a tuberculoma, 1 abscess, 1 case each of Fibro-lipoma, osteo-fibro-lipoma of posterior peritonem and 1 case of hematoma.
18. Lymph nodes
a) Cervical lymph nodes
26 out of 73 lymphatic involvement which is 35.6% of them belong to this cervical group and of these 18 or 70% were tubercular, the rest being 3 cases of syphilis, 3 simple fibrosis, 1 case each of diphtheria and lymph sarcoma.
b) Trochodreal lymph node
There was only one case of unsuspected lymph sarcoma of an early stage.
c) Inguinal group
1 Fibro-sarcoma which was from thigh, and 1 each cases of carcinoma and gonorrheal abscess and the cancer was also from secondary involvement.
d) Mesenteric lymph nodes
In total 33 cases 17 were cancers 16 from stomach, 1 from pancreas, 5 tuberculosis, 2 fibro-sarcomata, 1 lymph sarcoma others being simple adenitis. There was an extraordinary incidence of paragonimus westermanii infection of lymph node found on a material referred from Dr. Rogers of Soon-chun.
e) Axillary lymph nodes
There were 10 cases and of these 6 were secondary cancer from breast 2 were tubercular and others simple adenitis.
Beside those above mentioned, there was a case of acute multiple swelling of cervical as well as mediastinal lymph nodes without either fever or leukemia or monoleucocytosis but the patient was dismissed before any confirmative diagnosis could be made. The histological picture showed considerable hyperplasia of lymph follicles with increase of lymphocytes but not in the blood and our impression was an early case of Hodgkin's disease. One of the cases of Syphilis was on a child of 11 months old a case which had been referred from Dr. Rogers.
19. Breast
Of total 38 cases, 24 of them were confirmed in the clinical diagnosis of adeno-carcinoma. 19 being medullary in type and 5 scirrhous and there was a case of squamous cell cancer invading breast; the so called Paget's disease. 3 clinical diagnosis of carcinoma were found to be chronic mastitis, adeno-cystoma, and fibroma. The rest were adeno-fibromata in 2 cases, and mastitis and a few abscesses.
There was an unusual case of lipo-sarcoma of breast in whom the metastase was founed in mesenteric and axillary lymph nodes.
Another note-worthy case was that of carcinoma of breast found on a male breast of 65 years old.
20. Parotid glands (Sub-maxillary region)
2 cancers were noted one being adeno-papillary in type; 2 fibromata, 1 fibro-sarcoma, and 4 mixed tumors of which 2 cases were osteo-chondro-fibromata, 1 each cases of haemo-angio-chondro-fibroma, and adeno-myxo-fibroma, and also a case of squamous cell cancer was found. The one of the adeno-cancer appeared to be from sweat gland.
21. Thyroid gland
Among 23 cases involved in this organ, 7 were colloid retention, 8 papillary adenomata, 1 cancer, 7 hyperplasia, and 1 case of fetal adenoma; 1 cancer; 7 hypoplasia, and 1 case of fetal adenoma.
22. Skin
There were 149 cases comprising approximately 20% of this report; they were distributed from scalp to feet.
a) Scalp—On scalp region 4 squamous cell carcinomata and 2 basal cell carcinomata, 1 case each of papilloma, lipo-fibroma, 1 congenital wen in 15 month old child, 3 sebasceous cysts.
b) On face—4 small fibromata, 4 papillomata , 2 haemo-angiomata, 1 case each of fibro-sarcoma lymph-angioma and blastomycosis.
c) On neck—1 each, cases of haemo-angioma, multiple lipomata, and fibro-sarcoma which had been clinically diagnosed carcinoma and also a case of melano-sarcoma, keloid, mixed cell fibro-sarcoma.
d) On back—There were 5 cases in all and they were 2 lipomata and another lipoma was found to be lipo-sarcomatous in tendency 2 cases of horny papillomata.
e) On chest—3 cancers of squamous cell type, 1 each, cases of lymphangioma, cavenous angioma and melano-sarcoma.
f) On abdomen—3 sarcomata, 3 melanomata or pigmented moles, 1 each, cases of haemo-angio-fibroma, general fibromatosis, and Sebaceous cyst 2 others granular inflammation.
g) On arms—1 each cases of papilloma, tuberculosis, osteo-sarcoma, carcinoma mixed cell sarcoma, and a case of Ganglion or cystic tumor from tendon of muscle sheath.
h) On buttock—3 squamous cell carcinomata, 1 basal cell cancer, 1 very unusual case of parasitic cyst was found in a middle aged farmer's wife on very unusual location under the skin, and judged to be paragonimus westermanii; the parasite having wandered into abdominal cavity penetrated into pelvic tissue and then been carried to this location through blood vessels.
i) Legs—3 cases of clinically diagnosed carcinoma were found to be 1 each cases of Fibro-sarcoma, kearatonizing cancer, and gumma also 1 each cases of fibroma, and fbrosarcoma were found in addition.
j) Feet—On foot there was a case of clinically diagnosed lipoma which was found to be large round cell sarcoma and also 1 each, cases of angio-fibroma and keloid were on record.
k) Miscellaneous—There were still 50 more cases of skin lesions where the site of tissue had not been mentioned. When these are looked into their diagnoses are; 16 squamous cell carcinomata, 8 cases of fibro-sarcomata, 1 each cases of melanoma and melano sarcoma, 1 multiple sarcomatosis sent from Dr. Koh of Hamheung, 3 leprosy, 2 suspected blastomycotic granulation, 1 each cases of gumma, keloid and many dermatitis.
22. Bone and Joints
These consist of 12 cases of bone and 4 cases from joints. In 6 cases osteomyelitis 4 were tubercular in two other cases both on sternum Tbc. were not discovered. 1 other case of osteomyelitis of rib and 1 osteoma of tibia. In arthritis 3 Tbc. knee joints and another in sarco-illiac joint. 1 each cases of meningocele and teratoma of coccygeal region in different occasions on materials refered from Presbyterian hostital of Taiku.
23. Eye
There were 10 in all including eye balls and conjunctiva. 5 gliomata 1 each, cases of lipoma, tuberculoma, and abscess in orbital fossa.

SUMMARY

1. Tumors were found 411 out of 740 sections diagnosed which correspond to 55.5% of this report and of these 240 cases or roughly 60% (58.3) of them are Epithelial in origin and 136 or 33% from Connective tissue and 12 or 3% of them being from Endothelial lining cells. In non-tumourous tissues, Specific granulations such as Tuberculosis Syphilis, Leplosy and also non-specific granulation such as Blastomycosis, Keloid and other chronic and acute inflammatory tissues are included. Pregnancy and parasitic infections are also mentioned. In ovary 87%, in breast 78% and in uterus 56% were all tumors.
2. Carcinomata
Total 156 or 40% of all tumors enlisted in this report are carcinomata and of these 103 or 66% of them were adeno carcinoma, and the remainder of 34% are 50 squamous cell cancers and 3 basal cell cancers.
The site of most frequent occurrence are 65% on female breast. 63% of suspicious growth on penis were also carcinoma and on skin which is about 22% of tissue diagnosed.
3. Sarcoma
Sarcoma were found in 48 cases out of 411 tumor diagnosed which correspond to 11.6% and of these 39 or 80% of the sarcoma had been Fibro-sarcomata and the rest of 20% are distributed to 2 Lipo-sarcomata 2 Osteo-sarcomata, 2 Myo-sarcomata and 3 Melano-sarcomata. The Myo-sarcoma is rare tumor and we found in two cases one in uterus another on tongue. Beside these mentioned above, there were 3 cases of Lympho-sarcomata.
When the figures 156 cancers and 51 sarcoma added together the 50% of all tumors diagnosed belong to either of these types of malignancy, or 28% of whole 740 sections reported in this paper belongs to either carcinoma or sarcoma of some denominations.
It is interesting to note that when the tumors of both epithelial and connective tissue origin compared as to their malignancy it shows ;
      A. Epithelial     240 cases
malignancy        156 or   60%
B. Mesothelial    136 cases
malignancy        46 or    33.8%

thus shows that the tumors Epithelial origin has twice the malignant tendency over those of Connective tissue origin.
3. Fibromata
There were plenty of Fibromata 63 of them and largest number of the tumor was found in uterus as Myo-fibromata being 56% of all tumors or 20% of all uterine tissue diagnosis made. There was a case of general Fibromatosis; a small bean sized tumors found scattered all over the skin if the description of Dr. Choi of Kwanju be taken.
This histologically benign tumor was found in 18 cases largely on penis and the papillary adenomata were found all in Thyroid gland.
Pure adenoma is rare occurrence and in two cases of our own, 1 was fetal adenoma of thyroid and another adeno-fibroma on caecum.
There were total 56 of cystic tumors and of these 44 cases were found in Ovary which comprises 56% of tumor incidence of this organ.
The adeno-papillary-cystoma is said to be highly malignant in nature. We had a very interesting record of Dr. Hirst who found a small walnut sized cystic tumor in subcutaneous tissue of abdomen of a middle aged woman and having operated on this tumor the tissue was sent to us for diagnosis and it was found to be adeno-papillary tumor which is quite foreign to this part of structure and subsequently the mass in abdomen was opened and the tumor was traced to Ovary which was not conspicuously large enough to be felt over the abdomen.
The adeno-fibroma of caecum was rather instructive tumor as to its site of occurrence and having chronic inflammation superimposed on the neoplasm it was not easy to differentiate histologically from Condyloma.
6. Lipomata and Liposarcomata
We had several cases of lipomata some pure while others mixed with other histology for instance as Fibro-lipoma and osteo-fibro-lipoma and angio-fibro-lipoma. 1 case of multiple lipomatosis on abdomen and 2 cases of Lipo-sarcoma one in breast and another on back under the skin.
The tumors arising from lining endothelium of both blood and lymphatic vessels are rare and we had total 9 cases of which 6 are Haemo-angio-endothelioma and 3 of them being Lympho-angio-endotheliomatous in nature.
Among 6 of the haemo-angiomata, 1 was cavenous .and 2 of them were combined with other structures namely with Fibroma and with Lipoma.
7. Mixed Twmors
There were several note-worthy mixed tumors all from parotid regions and 2 cases of teratomata of coccygeal region from new born children. For example; Haemo-angio-chondro-fibroma, Osteo-fibro-lipoma and osteo- chondro-fibroma. 5 dermoid cysts, 1 case of Epinephroma in Kidney 2 hydatid moles from uterns, and Acanthoma from gum.
8. Tuberculosis
Tuberculosis was found in 68 cases comprising about 9% of whole report. The largest number and also its percentage was found in cervical lymph nodes, 70% of diagnosis on this cervical group of lymph node was tuberculous in change. The next most frequent site of occurrence was in peritoneal lymph nodes total 17 cases comprising about 28% of findings in abdominal cavity. The tuberculous changes observed in rare locations were; a case in Ovarian tumor, one on placental tissue, 2 cases on the gum of oral cavity, one case of Tubercular salphingitis, the pure Tbc. skin lesions are found only in two cases.
9. Syphilis
Syphilis were found in 12 cases, gumma on leg, on testicle, and in mouth and many on cervical lymph nodes 2 cases of chanquer etc.
10. Parasitism
Total 3 cases of parasitic granulations were all due to the paragonimus westermanii; 1 each cases in inguinal hernia sac, in omentum and also in subcutanea of buttock where a parasitic fluke was taken out from the sub-cutaneous cyst and kept preserved in our museum jar.

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