An Early Description of Carcinosarcoma in 1883

By 1804, John Abernethy was aware of the existence of a tumor which he called carcinomatous sarcoma. In this context, this paper presentshow, in 1883, David Finlay fully documented a case whose data were indicative of the formation of carcinosarcoma in a woman sufferingfrom fibroids. It is concluded that the “early” status of his recognition of this pathological entity merits documentation rather than usingthe nomenclature of “first.” The present submission is in line with the importance of drawing attention to remarkable historical milestones.Moreover, in terms of proper growth of the literature, this has been done through the English language which is the lingua franca.

Key words: Cancer; History; Carcinoma; Sarcoma; Carcinosarcoma

Well before microscopy came into vogue, the observant John Abernethy [1] of the “fascia fame” was able in 1804 to delineate the cancer type which he called “carcinomatons sarcoma”. In his own words, “the disease extends through the medium of the absorbing vessels.” Therefore, an early well described case is worthy of documentation.

Documentation of “carcinosarcoma” in the encyclopedic Ackerman’s Surgical Pathology [2] was simply in terms of tumors having only homologous, i.e., glandular and stromal elements. Properly called “carcinosarcoma” by Norris and Taylor [3], the homologous type shows only tissues that subsist in the organ [4]. In contrast, in the heterologous type, there are foreign tissues, e.g., cartilage in uterine cases [5].

With this clear distinction in focus, the report by David Finlay [6] to the Pathological Society of London on March 6^th, 1883, is worthy of abridged documentation:

The patients from whom the specimen was removed was a single woman, aged 59, admitted into the Middlesex Hospital under my care on October 4^th, 1882. She first noticed a hard swelling in the lower part of her belly fifteen years since, but suffered no inconvenience from it until quite recently, when it had seemed to increase more rapidly in size.

The patient died 8 days after admission. The autopsy findings were remarkable as follows:

The hypogastric and lower umbilical regions were occupied by a large tumor of globular form, and for the most part smooth, attached to the fundus of the uterus by a pedicle about an inch in width. It was adherent to numerous coils of intestine and in separating it from these a part of the investing capsule on its posterior surface was ruptured, and gave exit to a quantity of bloodstained fluid. On the summit of the tumor were found the two nodular masses which had been felt through the abdominal wall during life and between and behind these a part of the small intestine, to which the tumor was adherent was penetrated by the growth which appeared in the interior of the bowel as a rounded mass about the size of a sixpence.

Sixpence size description was in keeping with the language of yore. Moreover, spread was documented as being widespread. Involved were the urinary bladder, right lung, diaphragm, left ventricle, left kidney, and left cervical lymph node. Unfortunately, the neck and kidney samples were mislaid. However, the microscopical appearances were appreciated clearly thus:

In the same microscopic specimen may be seen tracts in which round-cell growth predominates, adjacent to and often apparently mixed up with typical spindle-cell growth. Separating these areas of cell growth, there are tracts of the normal constituents of the fibro-myxoma.

Fibro-myxoma, or the present day “fibroid,” was a well-known entity. In particular, it is important that true “carcinosarcoma” was figured as microscopical sections nicely as follows:

Fibro-myxoma differs from carcinosarcoma as is apparent on close inspection of (Figure 1). These arrangements bring to focus not only the fibrous elements but also the glandular elements. These elements are together an embodiment of true carcinosarcoma. Incidentally, it should be stressed that it was only in modern times that special staining methods came into practice (Figure 1).

Practice of historical interest is the reporting of a presumably early case of a named lesion. Thus, I used this appellation with reference to the cancer to cancer metastasis noted in 1848 [7]. Next, as regards Krukenberg tumors, some early descriptions were also supplied [8]. In this context, consider the “seed and soil hypothesis” which was recently described in terms of “ever since Paget first introduced” it [9]. In contrast, my historical article of 1975 was entitled “The origins of the soil theory of cancer metastasis” [10]. Incidentally, in it, I showed that, even his own father, James Paget [11], was aware that an organ must have an “apt” soil before it can be attacked during metastasis. In this vein, using the word, “early,” is preferable to that of “first.” Indeed, I had occasion to review the old literature in order to give several instances of “false firsts” [12]. In point of fact, as I illustrated elsewhere [13], English is firmly the lingua franca. Hence, it suffices for international communication.

Communication lesson, which accrued from this study of a carcinosarcoma of 1883 vintage, is the need to appreciate the historical antecedents in any field of oncology. For instance, the illustrious Australasian, Sir Macfarlane Burnet [14], promoted this idea during his 1977 address on the morphogenesis of cancer. As he put it, authors should be conversant with the history of their subjects. Earlier in 1933, Haagensen [15] had exhibited important books, papers, and memorabilia in order to illustrate the evolution of the knowledge of cancer. In sum, authors should beware that they do not regard as “firsts” what had been published before. In fact, it should be obligatory to use “early” – a broader connotation word! In conclusion, since English is the lingua franca [16], its use in scientific communication should be preferred. Personally, I have recently demonstrated this important dictum [13].