CARCINOMA OF THE BREAST IN HOMOLOGOUS T\VINS
SAMUEL A. MUNFORD, M.D.
AND
HUGH LINDER, M.D.
(From the Departments of Medicine and Surgery, Clifton Springs Sanitarium and Clinic, N. Y.)
The role of heredity in disease has interested observers since early times.
The recurrence of such diseases as hemophilia and peroneal atrophy in male
members of certain families illustrates well the sex-linked hereditary character
of these diseases. Likewise the direct inheritance of Huntington's chorea
seems well established. The part played by heredity in tumors has been less
easy to trace, however. It is generally agreed that certain types of cancer
can be hereditary in mice. Maud Slye (1) says: "That the occurrence of
FIG. 1.
PHOTOGRAPH OF TWINS, SHOWING IDENTICAL LOCATION OF TUMORS
cancer has its basis in inherited susceptibility seems now to be satisfactorily
established by the results obtained in many controlled breeding experiments."
Proof of the hereditary nature of the disease in man is less satisfactory.
Macklin (2) gives a number of reasons why it is so difficult for observers to
agree on this point. She reaches the conclusion that no matter what the
mechanism of inheritance is, whether the tumor tendency is inherited as a
single characteristic or whether it comes about by the influence of many factors, it is dependent on heredity.
Among the arguments assumed to be in favor of the hereditary nature of
tumors is the occurrence of similar tumors in similar positions in homologous
twins. It is with this argument in mind that the following cases are reported.
393
FIG. 2.
FIG.
3.
SOLID PORTION OF BREAST CARCINOMA.
X 200
AREAS IN BREAST CARCINOMA SHOWING COLI.ECnON or MUCOID MATERIAL BETWEEN
X 200
THE TUMOR TRABECULAE.
394
CARCINOMA OF THE BREAST IN HOMOLOGOUS TWINS
395
ABSTRACTS OF CASE HISTORIES
Mrs. C. W., a white widow, aged ninety-one years, was seen on April 9, 1935, because
of dyspnea which had begun two or three weeks previously. She had had a hard lump in
the left breast for approximately two years. It had grown slowly and had caused no pain
until recently, and no professional advice had been sought. Previous to the onset of the
present symptoms the patient had enjoyed excellent health. She was n<?w thin, cachectic,
in obvious respiratory distress. Lips and nail beds were cyanotic. The left breast was
almost replaced by a hard, somewhat tender mass which had apparently arisen in the upper
outer quadrant. The mass was fixed and the skin was obviously involved, being in places
very thin and discolored as if almost ready to ulcerate. No axillary nor supraclavicular
nodes were noted. The right breast was uninvolved. Examination of the chest revealed
the usual signs of fluid in the right pleural cavity. No fluid could be detected by physical
means in the left pleural cavity. X-ray studies were not practicable. After removal of
800 c.c, of bloody fluid the dyspnea was greatly improved, but fluid reaccumulated rapidly
and 1500 c.c. were removed on April 23, 1935. The patient became steadily worse, how-
~-r
FIG.
4.
0
/1Jq/e.
0
~m,,/c.
•
~m,,/. z;
t:,,,u,e;-
FAMILY HISTORY SHOWING CANCER OF LEFT BREAST IN THREE GENERATIONS
ever, and died June 4. Complete autopsy was not permitted, but a piece of the breast
tumor was removed. Photomicrographs of a section from this tumor are shown in Figs.
2 and 3.
Mrs. ]. M., a twin sister of the patient, was called in and examined. She, too, had had
a hard lump in the left breast for about two years. It had grown very slowly and had
never been incapacitating. She had no symptoms suggesting pulmonary metastases or chest
extension. Examination showed a hard, fixed tumor in the upper outer quadrant of the left
breast about 2 cm. in diameter. The skin was attached to the tumor and the mass in tum
to the chest wall. The nipple was not retracted and there was no discharge. No axillary
nor supraclavicular nodes could be felt. Chest examination was grossly negative otherwise.
This patient was seen again recently and no changes were noted. Because of her advanced
age, operation is not feasible and no sections are available. The clinical picture, however, is
so characteristic as to leave little doubt of the malignant nature of the tumor.
These two sisters were born Sept. 23, 1844, and have always lived in the same part of
the country. Both were married and their husbands are now dead. Mrs. C. W. had one
child. Mrs.]. M. had no pregnancies. The sisters were of similar temperament, their general body contour was similar, and there was a decided facial resemblance, as shown in
Fig. 1. The family history, obtained from the patients and their two sisters, is shown
graphically in Fig. 4.
396
SAMUEL A. MUNFORD AND HUGH LINDER
DISCUSSION
These two individuals present a striking illustration of the generalization
made by McFarland and Meade (3), that tumors appearing in homologous
twins may vary to a limited degree but are similar, symmetrical, and simultaneous. Another impressive example is found in Burkard's cases of benign
fibro-adenoma occurring in the same breast in single ovum twins (4). Kaplan
(5), however, reports carcinoma of the breast occurring in only one of homologous twin sisters. This would seem to be a direct contradiction to previous observations, but more time will have to elapse before this can be accepted as an exception. This is borne out by Champlin's report (6) of sarcoma of the testicle occurring in identical twins at the ages of twenty-four and
thirty-one. Both tumors occurred in the right testicle. Just why the tumor
in the first twin should have developed more rapidly than the other is not
known. It is possible that trauma may have been a factor but the history on
this point is questionable. It is interesting to note that in our cases the more
rapidly developing tumor occurred in a breast which had lactated.
SUMMARY
Cases of carcinoma of the breast occurring simultaneously and in the same
position in homologous twin sisters are reported. An interesting family history is also traced.
NOTE: The authors wish to thank Dr. C. C. Nesbitt of Palmyra, N. Y., for his cooperation in making it possible to follow these cases.
REFERENCES
1. SLYE, MAUD: The relation of heredity to cancer occurrence as shown in Strain 73, Am.
J. Cancer. 18: 535-582, 1933.
2. MACKLIN, M. T.: Role of heredity in disease, Medicine 14: 1-75, 1935. Human tumors
and their inheritance, Canad. M. A. J. 27: 182-187, 1932.
3. McFARLAND, ]., AND MEADE, T. S.: Genetic origin of tumors supported by their simultaneous and symmetrical occurrence in homologous twins, Am. J. M. Sc. 184: 66-80,
1932.
4. BURKARD, H.: Gleichzeitige und gleichartige Geschwulstbildung in der linken Brustdri.ise
bei Zwillensschwestern, Deutsche Ztschr. f. Chir. 169: 166-174,1922.
5. KAPLAN, IRA I.: Carcinoma of the breast in one of homologous twin sisters, Am.]. M. Sc.
190: 331-332,1935.
6. CHAMPLIN, H. W.: Similar tumors of testis occurring in identical twins, J. A. M. A. 95:
96-97, 1930.