- Email: [email protected]
Benign cystic teratoma of the ovary with extracystic segment of colon, an unusual case
BENIGN CYSTIC TERATOMA OF THE EXTRACYSTIC SEGMENT OF COLON, UNUSUAL CASE* J.
BERNARD BERNSTINE, PHILADELPHIA, PA.
(Prom the Departments Jefferson Medical College
of Obstetrics
and Gynecology,
OVARY AN
WITH
M.D., AND PAUL JERNSTROM,
Pathology,
and the Clinical
M.D.,
Laboratories,
Hospit&)
B
ENIGN cystic teratoma of the ovary is the accurate designation for the common neoplasm erroneously termed “dermoid cyst” since these tumors possesstridermal characteristics. We must be resigned to the continued use of the misnomer, dermoid cyst, however, for, as Nicholson6 stated, “The death of a dogma takes geological time.” Willis13 contended that highly organized structures are sometimes associated with benign cystic teratomas. In addition to digits, phalanges, metacarpals, and neural elements, intestine, possessing all coats as free coils, is encountered. Novak? also mentioned that intestinal loops are found in these tumors. A survey of the literature to November, 1957, however, discloses only five references to the occurrence of portions of adult type bowel forming an integral pa.rt of benign ovarian cystic teratomas, but all were apparently intracystic in location. 5l *-I1 The following case then, is a unique one of a benign cystic teratoma of the ovary with an estracapsular loop of mature colon. CZinicaZ Data.-For 3 weeks this 51-year-old, well-developed and nourished white woman complained of intermittent pain in the right flank which radiated posteriorly. It was accentuated when she assumed a reclining posture. The menarche was at the age of 15 years and menstruation was normal thereafter. She was gravida and para iv and had an unremarkable Physical examination disclosed the presence of a large menopause at the age of 48 years. mass in the lower right side of the abdomen. It extended from the level of the umbilicus down into the pelvis, felt cystic and movable. Pelvic examination confirmed the location of the cystic mass which nudged the uterus forward and pulled the cervix up behind the symphysis pubis. Results of laboratory tests were within normal limits. Roentgenographic examinations included an intravenous pyelogram and a barium enema study. A large pelvic softtissue mass was seen which reached the level of the fourth lumbar vertebra and contained calcifications suggestive of the presence of bone and/or teeth. The pyelogram showed the right ureter to be definitely displaced laterally around and apparently adherent to the cystic mass. This ureter was dilated from the level of the fourth lumbar vertebra to the brim of the pelvis and was not visualized well beyond this landmark. No intrinsic abnormality of the large bowel was noted in the barium contrast, but there was evidence of external pressure upon the distal sigmoid colon by the pelvic mass with displacement of the cecum up and out of the pelvis. The calcifications within the mass were cited again and the impression was that there was an ovarian tumor, probably a teratoma, in the pelvic cavity on the right side. *Presented
at a meeting
of the
Obstetrical
193
Society
of
Philadelphia,
Dec.
5, 1957.
and bro: was p0,
Subsequently, a right salpingo-oophoreetomy was performed following uterine dilatation curettage. When the abdomen was opened a large bluish cyst which was within the right The right broad ~3 ligament was encountered; it completely filled the pelvis. ligament divided in its upper part and the cyst mobilized and removed. The patient tol’ crated the ~lurrs well and her postoperative course was uneventful.
Pig. l.-Hrrnisectioned bulk of the contents ular bowel is noted
JOig,
z,--”
lhe
entire
on
thickness
benign cystic being pultaceous, the right.
of
teratoma sebaceous
of
the ovary material.
the extracystic segment layers or coats. (X50.1
of
mature
with The
the matted ha .ir on tou. attached loop of extw-
wlon,
all
Volume 77 Number I
BENIGN
Gross which the otherwise handlelike the capsule segment of
Pathological Examination.-The specimen consisted of a fresh, large, cystic right measured 17 by 12.5 cm. and the adherent Fallopian tube. A striking feature of gray-pink, smooth, and glistening external surface of the cystic mass was the attachment of a tubular structure which measured 8 by 1.5 cm. It was fixed to of the tumor by fibroadipose tissue so that this part of the specimen mimicked a intestine with its mesentery (Fig. 1).
ovary
CYSTIC
TERATOMA
OF
OVARY
WITH
COLON
SEGMENT
195
A copious amount of yellow-green, greasy, lardaceous material comingled with abundant dark-brown, coarse hair exuded when the mass was incised. The evacuated cyst had a fmely granular, pale pink to yellow-gray internal surface which, in the thicker portions, resembled the skin of the scalp. The wall measured from 0.2 cm., to the part comprising the mammilla or nipple, which was 2.0 cm. thick. The latter area contained a bone-hard core and was surrounded by pink-gray, variegated, firm tissue. Viscid black meconium-like material escaped from the double-blind loop of attached bowel when it wits opened. Its mucosa was stained green black and the wall was thin. This feature of the extracapsular loop of bowel is fascinating and lends itself to speculation since there was no biliary structure connected in any way with the specimen to account for the apparently bile-stained meconium-like contents. Yioroscopic Ezaminat,ion.-Study of the histologic sections from the of the ovarian cyst disclosed the presence of predominantly cutaneous appendages. Another ectodermal derivative encountered, in addition to sebaceous material present, was some retinal tissue of the eye. Mesoderm foci of cartilage and bone and the entoderm by respiratory epithelium and of the extracystic coil of intestine (Fig. 2). Thus, the clinical and diagnosis of a benign cystic teratoma of the ovary with an cxtrarapsular colon was verified histologically.
mammillary portion tissue replete with the skin, hair, and was represented by the colonic mucosa gross pathological segment of mature
Comment It is significant that authorities like Novak7 and Willis13, I4 mentioned that highly organized structures such as free loops of intestine and attached mesentery are sometimes found associated with benign cystic teratomas of the ovary. Perusal of the medical literature, however, discloses only 5 instances in which coils of adult intestine were found, and in each case the bowel originated within the cyst. Pommer,Q in 1890, described tissue resembling cecum and appendix within a cystic ovarian tumor. Shattock,12 in 1904, reported finding, in addition to poorly developed lower limbs and a vulva with pubic hair, coils of intestine in a celomic cavity. Andrews,l in 1912, mentioned the presence of a tubular structure attached to a mesentery projecting from the inner lining of an It was gut and even contained nerve ganglia in its coats. ovarian cystic tumor. Schoenholz,10 in 1923, discovered a double-blind loop of large intestine, one end The of which was attached to the dermoid plug and the other to the cyst wall, gut hung outward into the carrier’s abdomen through a cleft in the cyst, apparently a defect in its wall. Schottenfeld and Littauer,l’ in 1938, also reported a cyst of the ovary containing an appendix and portion of ileum attached to the inner surface. WillisX3 cited several cases wherein segments of intestine were found associated with benign cystic teratomas involving tissues and organs of the body other than the ovary, such as the sacrococcyx. The case herein presented, then, is, to the best of our knowledge, the first describing the presence of a segment of mature intestine attached to the external surface (extracystic) of a benign cystic teratoma of the ovary.
Summary A tumor is described that is believed to be t,he first example of a benign cystic teratoma of the ovary with an extracystic segment of mature colon. The clinical, roentgenographic, and gross and microscopic pathologic aspects of benign cystic teratomas of the ovary are reviewed.
BEHNSTINE
196 We histologic
wish to thank preparations.
Margaret
Endel
AND for
the
Am. J. Obst. & Gynec. Janvary. 1950
JERNSTROM illustrations
and
Regina
Nekludov
for
the
References 1. Andrews, a. Blackwell, 13 . 4. 5. 6. 7. 8. 9. 10.
II. IS. 2
H. R.: Proc. Roy. Sot. Med. 62: 54, 191% W. J., Dockerty, M. B., Masson, J. C., and Mussey, R. J).: hM. I. 0%‘~‘. L GYNEC. 51: 1.51, 1946. Coleock, B. P., Sass, R. E., and Standinger, L.: New England J. Med. 252: 373, 1955. Frank, R. T.: Gynecological and Obstetrical PatholorJ, cd. 2, New York, 1931, 1). Appleton and Company, p. 361. Herbut, P. A.: Gynecological and Obstetrical Pathology, Philadelphia, 1953, Lea E Febiger, p. 389. Nicholson, G. W.: Studies on Tumor Formation, St. Louis, 1950, The C. V. Most)? Company. Novak, E.: Gynceologic and Obstetric Pathology, cd. 3, Philadelphia, 1952, W. H. Saunders Company, p. 442. Peterson, TV. E‘., Prevost, E. C., Edmunds, F. T., Hundlcp, .J. M., Jr.! and Morris, F. K.: AM. J. OBST. & GYNEC. 70: 368, 1955. Quoted by Ewinp. James: Neoplnstic I>ischases : A Treatise on ‘J’urnr~r.s. Pommer. C. P.: Philadelphia, -1940, ti. B. S&ders CornpanG, p. 676. Schoenholz, 1,. : Zentralbl. Gyn%k. 43: 1363, 1923. Schottenfeld, L. E., and Littauer, E. .V.: Aw. J. ORST. R- UYNEC. 35: 889, 193% Shattock, P. E.: Laneet 2: 1284, 3304. Willis, R. A.: Pathology of Tumours, J,ondon, 1948, Bnttcrworth & Co., J,t,ll. Willis, R. A. : Tcratomas in Armed Forces Institute of Pathology, Atlas of ‘I’u~r~or Pathology, Section III, Fasciele 9, Washington, D. C., 1951, pp. 9.37.
BERNARD BERNSTINE, PHILADELPHIA, PA.
(Prom the Departments Jefferson Medical College
of Obstetrics
and Gynecology,
OVARY AN
WITH
M.D., AND PAUL JERNSTROM,
Pathology,
and the Clinical
M.D.,
Laboratories,
Hospit&)
B
ENIGN cystic teratoma of the ovary is the accurate designation for the common neoplasm erroneously termed “dermoid cyst” since these tumors possesstridermal characteristics. We must be resigned to the continued use of the misnomer, dermoid cyst, however, for, as Nicholson6 stated, “The death of a dogma takes geological time.” Willis13 contended that highly organized structures are sometimes associated with benign cystic teratomas. In addition to digits, phalanges, metacarpals, and neural elements, intestine, possessing all coats as free coils, is encountered. Novak? also mentioned that intestinal loops are found in these tumors. A survey of the literature to November, 1957, however, discloses only five references to the occurrence of portions of adult type bowel forming an integral pa.rt of benign ovarian cystic teratomas, but all were apparently intracystic in location. 5l *-I1 The following case then, is a unique one of a benign cystic teratoma of the ovary with an estracapsular loop of mature colon. CZinicaZ Data.-For 3 weeks this 51-year-old, well-developed and nourished white woman complained of intermittent pain in the right flank which radiated posteriorly. It was accentuated when she assumed a reclining posture. The menarche was at the age of 15 years and menstruation was normal thereafter. She was gravida and para iv and had an unremarkable Physical examination disclosed the presence of a large menopause at the age of 48 years. mass in the lower right side of the abdomen. It extended from the level of the umbilicus down into the pelvis, felt cystic and movable. Pelvic examination confirmed the location of the cystic mass which nudged the uterus forward and pulled the cervix up behind the symphysis pubis. Results of laboratory tests were within normal limits. Roentgenographic examinations included an intravenous pyelogram and a barium enema study. A large pelvic softtissue mass was seen which reached the level of the fourth lumbar vertebra and contained calcifications suggestive of the presence of bone and/or teeth. The pyelogram showed the right ureter to be definitely displaced laterally around and apparently adherent to the cystic mass. This ureter was dilated from the level of the fourth lumbar vertebra to the brim of the pelvis and was not visualized well beyond this landmark. No intrinsic abnormality of the large bowel was noted in the barium contrast, but there was evidence of external pressure upon the distal sigmoid colon by the pelvic mass with displacement of the cecum up and out of the pelvis. The calcifications within the mass were cited again and the impression was that there was an ovarian tumor, probably a teratoma, in the pelvic cavity on the right side. *Presented
at a meeting
of the
Obstetrical
193
Society
of
Philadelphia,
Dec.
5, 1957.
and bro: was p0,
Subsequently, a right salpingo-oophoreetomy was performed following uterine dilatation curettage. When the abdomen was opened a large bluish cyst which was within the right The right broad ~3 ligament was encountered; it completely filled the pelvis. ligament divided in its upper part and the cyst mobilized and removed. The patient tol’ crated the ~lurrs well and her postoperative course was uneventful.
Pig. l.-Hrrnisectioned bulk of the contents ular bowel is noted
JOig,
z,--”
lhe
entire
on
thickness
benign cystic being pultaceous, the right.
of
teratoma sebaceous
of
the ovary material.
the extracystic segment layers or coats. (X50.1
of
mature
with The
the matted ha .ir on tou. attached loop of extw-
wlon,
all
Volume 77 Number I
BENIGN
Gross which the otherwise handlelike the capsule segment of
Pathological Examination.-The specimen consisted of a fresh, large, cystic right measured 17 by 12.5 cm. and the adherent Fallopian tube. A striking feature of gray-pink, smooth, and glistening external surface of the cystic mass was the attachment of a tubular structure which measured 8 by 1.5 cm. It was fixed to of the tumor by fibroadipose tissue so that this part of the specimen mimicked a intestine with its mesentery (Fig. 1).
ovary
CYSTIC
TERATOMA
OF
OVARY
WITH
COLON
SEGMENT
195
A copious amount of yellow-green, greasy, lardaceous material comingled with abundant dark-brown, coarse hair exuded when the mass was incised. The evacuated cyst had a fmely granular, pale pink to yellow-gray internal surface which, in the thicker portions, resembled the skin of the scalp. The wall measured from 0.2 cm., to the part comprising the mammilla or nipple, which was 2.0 cm. thick. The latter area contained a bone-hard core and was surrounded by pink-gray, variegated, firm tissue. Viscid black meconium-like material escaped from the double-blind loop of attached bowel when it wits opened. Its mucosa was stained green black and the wall was thin. This feature of the extracapsular loop of bowel is fascinating and lends itself to speculation since there was no biliary structure connected in any way with the specimen to account for the apparently bile-stained meconium-like contents. Yioroscopic Ezaminat,ion.-Study of the histologic sections from the of the ovarian cyst disclosed the presence of predominantly cutaneous appendages. Another ectodermal derivative encountered, in addition to sebaceous material present, was some retinal tissue of the eye. Mesoderm foci of cartilage and bone and the entoderm by respiratory epithelium and of the extracystic coil of intestine (Fig. 2). Thus, the clinical and diagnosis of a benign cystic teratoma of the ovary with an cxtrarapsular colon was verified histologically.
mammillary portion tissue replete with the skin, hair, and was represented by the colonic mucosa gross pathological segment of mature
Comment It is significant that authorities like Novak7 and Willis13, I4 mentioned that highly organized structures such as free loops of intestine and attached mesentery are sometimes found associated with benign cystic teratomas of the ovary. Perusal of the medical literature, however, discloses only 5 instances in which coils of adult intestine were found, and in each case the bowel originated within the cyst. Pommer,Q in 1890, described tissue resembling cecum and appendix within a cystic ovarian tumor. Shattock,12 in 1904, reported finding, in addition to poorly developed lower limbs and a vulva with pubic hair, coils of intestine in a celomic cavity. Andrews,l in 1912, mentioned the presence of a tubular structure attached to a mesentery projecting from the inner lining of an It was gut and even contained nerve ganglia in its coats. ovarian cystic tumor. Schoenholz,10 in 1923, discovered a double-blind loop of large intestine, one end The of which was attached to the dermoid plug and the other to the cyst wall, gut hung outward into the carrier’s abdomen through a cleft in the cyst, apparently a defect in its wall. Schottenfeld and Littauer,l’ in 1938, also reported a cyst of the ovary containing an appendix and portion of ileum attached to the inner surface. WillisX3 cited several cases wherein segments of intestine were found associated with benign cystic teratomas involving tissues and organs of the body other than the ovary, such as the sacrococcyx. The case herein presented, then, is, to the best of our knowledge, the first describing the presence of a segment of mature intestine attached to the external surface (extracystic) of a benign cystic teratoma of the ovary.
Summary A tumor is described that is believed to be t,he first example of a benign cystic teratoma of the ovary with an extracystic segment of mature colon. The clinical, roentgenographic, and gross and microscopic pathologic aspects of benign cystic teratomas of the ovary are reviewed.
BEHNSTINE
196 We histologic
wish to thank preparations.
Margaret
Endel
AND for
the
Am. J. Obst. & Gynec. Janvary. 1950
JERNSTROM illustrations
and
Regina
Nekludov
for
the
References 1. Andrews, a. Blackwell, 13 . 4. 5. 6. 7. 8. 9. 10.
II. IS. 2
H. R.: Proc. Roy. Sot. Med. 62: 54, 191% W. J., Dockerty, M. B., Masson, J. C., and Mussey, R. J).: hM. I. 0%‘~‘. L GYNEC. 51: 1.51, 1946. Coleock, B. P., Sass, R. E., and Standinger, L.: New England J. Med. 252: 373, 1955. Frank, R. T.: Gynecological and Obstetrical PatholorJ, cd. 2, New York, 1931, 1). Appleton and Company, p. 361. Herbut, P. A.: Gynecological and Obstetrical Pathology, Philadelphia, 1953, Lea E Febiger, p. 389. Nicholson, G. W.: Studies on Tumor Formation, St. Louis, 1950, The C. V. Most)? Company. Novak, E.: Gynceologic and Obstetric Pathology, cd. 3, Philadelphia, 1952, W. H. Saunders Company, p. 442. Peterson, TV. E‘., Prevost, E. C., Edmunds, F. T., Hundlcp, .J. M., Jr.! and Morris, F. K.: AM. J. OBST. & GYNEC. 70: 368, 1955. Quoted by Ewinp. James: Neoplnstic I>ischases : A Treatise on ‘J’urnr~r.s. Pommer. C. P.: Philadelphia, -1940, ti. B. S&ders CornpanG, p. 676. Schoenholz, 1,. : Zentralbl. Gyn%k. 43: 1363, 1923. Schottenfeld, L. E., and Littauer, E. .V.: Aw. J. ORST. R- UYNEC. 35: 889, 193% Shattock, P. E.: Laneet 2: 1284, 3304. Willis, R. A.: Pathology of Tumours, J,ondon, 1948, Bnttcrworth & Co., J,t,ll. Willis, R. A. : Tcratomas in Armed Forces Institute of Pathology, Atlas of ‘I’u~r~or Pathology, Section III, Fasciele 9, Washington, D. C., 1951, pp. 9.37.