Document gbDOerYKem5JNXa3qMXw406E3

FILE NAME Talc TALC DATE 0000 DOC TALC031 DOCUMENT DESCRIPTION Medical Journal Article - Talcum Powder Granuloma TALCUM POWDER GRANULOMA ROBERT FIENBERG BOSTON M.D. with talcum powder granuloma could be Only one article dealing devoted mainly found in the literature This was an article by Antopol A short description of one case was given to lycopodium granuloma found in the presence of aniso- in which a foreign body reaction was tropic crystals which morphologically resembled talc crystals mag- MgO.4SiO2.H O nesium silicate who entered the hospital with My interest was aroused by a patient a diagnosis of tumor of the abdominal wall REPORT OF CASES a had had an appendectomy and hernior- - 44 year old woman in the present instance CASE rhaphy in another hospital seven years prior to extahemirneagtiioonnof the old appendectomy a Six years later she had slightly tender mass in loss in weight Examination showed scar There was no diarrhea constipation or in the subcutaneous a small firm mass at the upper end of the scar apparently tissuesexploratory made with excision of the scar It was An exploratory laparotomy was nodular tissue occupied much of the observed that an unusutahlisgrexatyentsriavnesliuncfeinlttration the abdomen was opened Over In the fascia On account of translucent nodular plaques were slightly raised grayish the entire cecum nodules and a generalized scattering omentum were several small translucent tissue Enlarged firm lymph nodes lay above the were of thin translucent granular On the lateral wall of the gallbladder stomach in the preaortic region The scar nodules The appendix was absent three small grayish translucent with section of the anterior fascia rectus in the abdominal wall was excised - muscle and peritoneum about thsehotrutmlyorbefore this paper was written so that The patient was discharged and the ultimate course is unknown fat and muscle 12 consisted of a piece of skin subcutaneous The specimen skin measured 9.5 by 3.5 cm and contained a scar 7 cm long by 6 by 3 cm The fat was dense gray and The tissue between the muscle andwhitthee sturbacbuetcaunleaoeusThis tissue extended into Also translucent with opaquaendgrcayoirsihum in an irregularly radiating manner the subcutaneous fat tissue 6.5 by 3 by 1.5 cm The there was a piece of muscle and connective connective tissue was firm translucent slightly granular pinkish gray From the Laboratory of Pathology New England Deaconess Hospital 1. Antopol W Arch Path 326 1933 has been described Owen 1a Recently a case of glove powder granuloma M Texas State J. Med 482 1936 FIENBERG Microscopic Examination stain An extensive lesion was s sue in which numerous pseudotu Talcum powder granuloma Pseudotubercles containing nume invade the subcutaneous fat of the corium subcutaneous fat and mi of rounded collections of fibrobl foreign body giant cells In addit tubercles as well as a few infre NULOMA M.D. wder granuloma could be Antopol devoted mainly on of one case was given in the presence of aniso- ibled talc crystals mag- "entered the hospital with FIENBERG POWDER granuloma 37 Microscopic Examination Sections extensive extensive Examination stain An sue in which were prepared with methylene blue lesion was seen consisting of dense hyaline connective tisnumerousnumerous pseudotubercles were present The lesion involved the appendectomy and a hernior- ination in the present instance region of the old appendectomy 1 weight Examination showed apparently in the subcutaneous excision of the scar It was r tissue occupied much of the he abdomen was opened Over slucent nodular plaques In the ; and a generalized scattering m lymph nodes lay above the wall of the gallbladder were pendix was absent The scar of the anterior fascia rectus his paper was written so that ibcutaneous fat and muscle 12 and contained a scar 7 cm long neous fat was dense gray and lae This tissue extended into ilarly radiating manner Also sue 6.5 by 3 by 1.5 cm The granular and pinkish gray gland Deaconess Hospital oma has been described Owen . Talcum powder granuloma case Pseudotubercles containing invade subcutaneous numerous 1 . 1 methylemneethylene blue stain ^ 48 foreign multinucleatedmultinucleamultitnucleateed d foreign body giant giant cells invade the subcutaneous fat of the abdominal wall The corium subcutaneous fat and muscle more well defined nodules consisted of rounded collections of fibroblasts andand endothelial cells with foreign body giant cells aIdndaiditiontiadodnition lymphocytes were noted witnhiunmetrhoeuspseluadrog-e tubercles as well as a fewfew infrequent polymorphonuclear leukocytes Flattened ~ 38 ARCHIVES OF PATHOLOGY elongated fibroblasts occurred at the periphery Here and there one or two giant cells were present surrounded in some instances by a few endothelial cells The giant cells contained numerous oval nuclei with These nuclei were at times arranged in a semicircle small chromatin masses at the periphery and at other times were scattered throughout the cell The cytoplasm of the giant cells was abundant and often small spaces were visible within it apparently containing crystals In some regions coalescence of the nodules had occurred Under crossed Nicol prisms numerous anisotropic crystals were visible within the giant cells The diagnosis was a foreign body reaction CASE 2. 67 year old woman five years previously had been given a diagnosis of primary hyperthyroidism and had a subtotal thyroidectomy in two stages The pathologic diagnosis was primary hyperplasia of the thyroid gland with moderate involution In the present instance she was admitted for a swelling which had been present in the region of the thyroid gland during the past three years The left lobe of the gland was easily felt the isthmus was partly sub- sternal There was no evidence of hyperthyroidism The basal metabolic rate was 4. It was felt that the remnants of the thyroid gland were a potential source of trouble and should be removed An excision of the thyroid remnants was made Following the operation , amount the basal metabolic rate was + 11 The specimen consisted of four irregular firm scraps of thyroid tissue the total weight of which was 20 Gm A small of muscle was attached There was much increase in fibrous tissue The thyroid tissue was translucent , and pink Microscopic Examination sections were prepared with the hematoxylin and eosin stain An extensive lesion was seen consisting of fibrosis and well developed pseudotubercles Material staining with hematoxylin was present about . some collections of crystals within giant cells Under crossed Nicol prisms numerous anisotropic crystals were found within the giant cells The diagnosis was primary hyperplaswiitah late involution and hyperinvolutionrecurreanntd a foreign body reaction A mineralogical analysis revealed that the crystals in the giant cells in both the foregoing cases possessed the following physical characteristics oe 1. The extinction angle varied from 10 to 15 degrees 2. Some crystals were in the orthorhombic and some in the mono- clinic system sO 3. The crystals had a higher refractive index than 1.54 Talc crystals possess an index of refraction Canada balsam of 1.589 along two axes . 4. The crystals were anisotropic 5. The crystals were roughly of the same magnitude and morpho- logic appearance as those in talcum powder Further evidence of a mineralogical nature was obtained by incin- eration Paraffin sections unstained were incinerated at about 400 C. for fiv tion in Th to an files 0 cases 1 were : other but it CAS border in the lip at a The pa Exa surgica was fir enlarge slightly carcino A1 submax Mic area of eosin s fairly 1 ments formati by and The obtaine slight occurre CAS on the years 1 formed at that was m An men c membr indurat Mic stain scar ti taining In tissue ~ LOGY e and there one or two giant by a few endothelial cells ith small chromatin masses cle at the periphery and at - cytoplasm of the giant cells ithin it apparently containing les had occurred c crystals were visible within reviously had been given a subtotal thyroidectomy in two erplasia of the thyroid gland was admitted for a swelling d gland during the past three . the isthmus was partly sub.m The basal metabolic rate yroid gland were a potential de Following the operation scraps of thyroid tissue the ount of muscle was attached . thyroid tissue was translucent repared with the hematoxylin onsisting of fibrosis and well hematoxylin was present about pic crystals were found within te involution and hyperinvolu- the crystals in the giant ed the following physical to 15 degrees bic and some in the mono- index than Canada balsam refraction of 1.589 along ne magnitude and morpho- ure was obtained by incin- incinerated at about 400 FIENBERG POWDER GRANULOMA 39 for five hours on two successive days Examination revealed no alteration in the crystals The significant results obtained in the study of these two cases led to an investigation of all the records of foreign body reactions in the files of this laboratory During a period of nine years only three other cases had occurred in which crystals resembling those in talcum powder were apparently responsible for clinically important lesions Several other cases were discovered in which a reaction to crystals was present _ but it was overshadowed by that due to suture material CASE - 50 year old woman had had a blue spot on the mucocutaneous border of the lower lip for a number of years There had been a slight increase in the size of the lesion during a few months previous to an operation on the lip at another hospital four weeks prior to examination in the present instance The pathologic diagnosis was basal cell carcinoma Examination showed on the left of the median line of the lower lip a healed surgical scar 1 cm in length One portion of the scar 0.4 cm in diameter was firm and nodular In the left side of the neck there were from two to five enlarged palpable lymph nodes The submaxillary gland on the left side was slightly larger than that on the right The clinical diagnosis was recurrent carcinoma lesion A shaped excision of the submaxillary triangle : was made with later dissection of the Microscopic Examination segment of the lip containing a small indurated area of mucosa was sectioned and the sections were treated with the hematoxylineosin stain Dense scar tissue extended into the muscle from the corium with fairly numerous foreign body giant cells present Laterally whorl arrangements of fibroblasts surrounded the foreign body giant cells The pseudotubercle formation was not well advanced Numerous anisotropic crystals were surrounded by and contained within the foreign body giant cells The diagnosis was a foreign body reaction The diagnosis of the lesion in tissue obtained in the submaxillary dissection was hyperplasia of the lymph nodes and slight chronic inflammation of the submaxillary gland No anisotropic crystals occurred within the lymph nodes CASE - 54 year old man had had fifteen years previously a furuncle on the left side of the lower lip about 2 cm from the mucocutaneous line Two years prior to examination in the present instance a small nonulcerated crater formed in the center of the old cicatricial tissue This was treated with radium at that time About one month before examination an excision of scar tissue was made at another hospital The pathologic diagnosis was carcinoma An excision of recurrent carcinoma and plastic repair were made The speci- men consisted of a small triangular piece of lip covered by skin and mucous membrane The skin showed a small depressed area with some thickening and induration beneath it Microscopic Examination were prepared with the hematoxylin stain Dense scar tissue extended from the corium to the muscle Within the scar tissue were small groups of foreign body giant cells surrounding and containing anisotropic crystals Scattered lymphocytes were present In one section a small focus of tumor was surrounded by dense fibrous tissue in which numerous anisotropic crystals were present within foreign body k 40 ARCHIVES OF PATHOLOGY giant cells The tumor tissue was arranged in the form of hair follicles occupying about three quarters of a low power field Invasion was fairly active The cells were small with oval nuclei containing fine chromatin granules The cyto- plasm was scanty the cell outlines indistinct Mitotic figures were not numerous There was palisading of cells at the edges The diagnosis was chronic inflammation and a small focus of basal cell carcinoma scar tissue a apparently of foreign body reaction the hair matrix type This focus was found only after many sections had been examined CASE - 23 year old man had a swelling on the right side of the perineum which appeared three weeks prior to his first admission to the hospital This steadily increased in size and became tender Examination disclosed that in the right anterior perineal region there was an sized indurated tender swelling with fluctuation at the center There was no induration along the wall of the rectum Incision and drainage were carried out The patient was again admitted two weeks later An opening was made in the fistula seen at the site of the previous incision for drainage in the right anterior perineal region A probe was passed along the left wall of the rectum but no internal opening could be demonstrated The condition was diagnosed as blind external fistula in ano Radical excision was performed The specimen consisted of a piece of skin and subcutaneous fat 4 by 2.5 by 1.5 cm The skin 2.5 by 1 cm was traversed by an incision which led into a sinus 1.2 by 0.2 cm in diameter running the lengtohf the specimen There was blue discoloration about the incision The surrounding tissue was fibrotic fibrosis extended hematoxylin Microscopic Examination were prepared with the stain The sinus tract was lined by granulation tissue which was infiltrated scar tissue with numerous lymphocytes About the sinus tract was dense also heavily infiltrated with lymphocytes This into the fat Within . the fibrous tissue were numerous anisotropic crystals many of which were within numerous foreign body giant cells Crystals and giant cells were close to the , , , . sinus The diagnosis was a fistula with chronic inflammation and a foreign body giant cell reaction All of the crystals in the last three cases resembled those found in the first two Furthermore in morphologic character they were strik- ingly similar to talc crystals which were mounted in glycerin and examined under the microscope / i EXPERIMENTAL STUDY Three adult mice were used In each mouse 1 cc of a sterilize1d0 per cent sus- pension of talcum powder in distilled water was injected subcutaneously into the abdominal wall as well as intraperitoneally At the end of seven weeks the mice were chloroformed and examined The findings were more or less similar in all Firm opaque white nodules about 0.3 cm in diameter were found in the subcutaneous tissues of the anterior abdominal wall at the point of injection Within the peritoneal cavity similar nodules covered by smooth serosa were found on the serosal surfaces of the spleen liver and small and large intestines as well as within the mesentery of the small intestine and omentum These nodules measured from 0,1 to 0.3 cm in diameter Some of the larger nodules both in the anter of unaltered Microsco stain The granulomato containing < described 1 a rather th endothelial visible The and of the . There wa invasion of centrally w body giant I but this wa remained in In the physical cl were prese & morpholog It is of necessary 1 seven year error in th talc during An ana only after the true na In the . - and it was to be dan present E In the 1 the lip In OGY of hair follicles occupying on was fairly active The matin granules The cytofigures were not numerous ue a foreign body reaction y of the hair matrix type d been examined right side of the perineum ssion to the hospital This nation disclosed that in the d indurated tender swelling ation along the wall of the An opening was made in the rainage in the right anterior wall of the rectum but no ion was diagnosed as blind abcutaneous fat 4 by 2.5 by in incision which led into a of the specimen There was ng tissue was fibrotic 1 with the hematoxylin issue which was infiltrated was dense scar tissue also xtended into the fat Within . _ many of which were within riant cells were close to the amation and a foreign body resembled those found in character they were strik- nounted in glycerin and Y of a sterilize1d0 per cent sus- ected subcutaneously into the the end of seven weeks the gs were more or less similar 1 diameter were found in the all at the point of injection by smooth serosa were found mall and large intestines as and omentum These nodules of the larger nodules both FIENBERG POWDER GRANULOMA 41 in the anterior abdominal wall andand within the peritoneal of unaltered dry powder cavity possessed centers staiMnicrTohsceopniocduElexs ademscirinbead tinithoe n were prepared with the hematoxylin granulomatous tissue with macroscopic examination were composed of numerous foreign body giant cells surrounding and containing described anisotropic crystals similar to thosethose found in the described There was much fibroblastic proliferation about the scurrygsitcaalls sAptecitmiemness a rather thick fibrousfibrous capsule formed at the periphery In addition scattered endothelial cells lymphocytes and a few polymorphonuclear visible There was invasion of the fat of the leukocytes were and of the omentum by the granulomatous tissumeesentery of the small intestine There was localized compression of the spleen and liver by large nodules but invasion of parenchyma In some of the larger nodules crystals no centrally with a few necrotic phagocytic cells visible Fibroblasts waenrde fporreesiegnnt body giant cells were present at the periphery No tubercle formation but this was probably due to the fact that the time was seen remained in the animals had been during which the crystals comparatively short COMMENT characteristics makes physical In the first two cases the results obtained following incineration showed that the crystals were mineral This together with their were present In idtehnetilcaasltwith morphologically it practically certain that tale crystals three cases the crystals were found to be those in the first two cases and with * ' talc crystals examined under the microscope That talc crystals may produce lesions similar to those found the cases studied is brought out by the results obtained in animal experimentation period It is of great interest that in the first two cases the length of time necessary to produce clinically perceptible masses ranged from five to seven years This long of time might be the cause of clinical error in that the possibility of the introduction of a foreign body like talc during the previous operation might be forgotten An analysis of the cases affords much instruction One is struck . : by the varied character of the cases in which talc crystals introduced a cause of diagnostic error In the first case an exploratory laparotomy was done for a suspected tumor of the abdomen Even examination g during the operation did not reveal the error which was further masked by the diagnosis of tuberculosis suggestebdy the frozen section It was only after the section was examined under crossed Nicol prisms that the true nature of the lesion was suspected In the second case the patient had suffered from hyperthyroidism 'a.nd * it was natural that the nodules palpable in the neck were thought to be dangerous although no symptoms of hyperthyroidism were : present Here too the presence of a foreign body was unsuspected In the next two cases lesions were presented in still another the lip In the first of these recurrent carcinoma region was suspected but the 42 ARCHIVES OF PATHOLOGY nodule was found to be caused by a foreign body reaction to crystals On the other hand the presence of crystals in the second case caused a lesion to be suspected which alone would probably have been missed for some time and in this way proved to be a boon to the patient _ While the last case one of a fistula in ano presented no difficulty in diagnosis it offered evidence that talc crystals in some instances may be responsible for keeping sinuses open Although cases of the type described are admittedly rare 5 in 30,000 the surgical lesions suggest that the indiscriminate use of talcum powdeorn gloves is to be avoided Washing the gloves before entering the operative field tends to prevent such granulomas In view of the _ extensiuvsee of the dry technic the rarity of such a complication sug- gests the possibility of individual variation in the reactions of patients - The cases offer another example of the harmfulness of silicates in the human body While rare the lesions may be cause of diagnostic ne ~ : error caused by anisotropic lesions which the crystals revealed the under varied circumstances varied circumstances - The value of examination of suspicious sections under crossed Nicol prisms isstressed talcum The indiscriminate use of talcum powder in the operating room may 9 produce granulomatous lesions PATH The pat have not 1 Flexner an of this kind number of such a met