Cervical carcinoma in a girl of sixteen years

536

AMERICAN

JOURKAL

OF

OBSTETRIC’S

AKD

(:YNECOLOGT

REFERENCES (1) HaadAeicher, E:. B. M.: J. Obst. & Gynec. &it. Emp. 17: 20X, 1916. (2) 1). ReckZinghawen: Die Adenomyome und Cystadenome des Uterus und Tubenwandung-ihre Abkunft von Resten des Wolffschen Korpers, Strassburg, 1896. (3) Rieder : Arch. f. path. Anat. von Virchow 96: 100, 1884. (4) Eossmaltn: Arch. f. GynLk. 54: 359, 1897. (5) Chiori: Ztschr. f. Heilk. 8: 457, 1887. (6) Meyer, Robert: Ztschr. f. Geburtsh. u. Gynak. 49: 464, 1903. Virchows Arch. f. Path. Anat. 172: 394, 1903. Ztschr. f. Geburtsh. II. GynLk. 47: 401, 1902. Ztschr. f. Geburtsh. u. GynLk. 38: 234, 1898. Faber Epithel Gebilde in Myometrium bei Ztschr. f. Geburtsh. u. Gynlk. 42: 43, 44, 1900Foten 71. Kindern, Berlin, 1899. 1901. (7) Blownt, 8. E’.: Am. J. Obst. 52: 210, 1905. (8) Risch: Traumatische Epithelcysten der Vagina (quoted by Haarbleicher). (9) As&off, L.: Cysten. Ergebnisse der Allgemeinen Pathologic, Jahrgang 1395 ; 2nd year, 456-565 Lubarsch, Ostertag. (10) C,uZZen, 2’. H.: Tr. South. Surg. & Gynec. Assn. 25: 142, 1912. CuZZen and Kelly: Myomata of the Uterus, Philadelphia, 1909, W. B. Saunders Co. (11.) Rosenthal, I.: Cystis intramuralis uteri e canali Gartneri, Endometritis polyposa, Medycyna, Varsovie, April 22, 1900. (12) Ottow, B.: Ztschr. f. Geburtsh. u. Gynak. 94: 540, 1928. (13) Fdcushim, K.: Zemralbl. f. Gynak. 2: 2238, 1927. (14) P&ram, E.: Arch. f. Gynlk. l29: 271, 1927. (15) Dworzak, H. : Arch. f. Gyntik. 150: 631, 1932. (16) Fink, K.: Zentrdbl. f. GynLk. p. 299, 1929. (17) Enau.er : Zentralbl. f. GynHk. p. 498, 1X93. (18) Breus: tiber wahrr Epithel fiihrende Cystenbildungen in Uterusmyomen. Wien. Deuticke, 7 894. (19) Amod: Ztschr. f. Geburtsh. u. Gynlk. 68: 347, 1906. (20) 1’. Arx: Ztsohr. f. Geburtsh. u. Gynlk. 79: 52, 1917. (21) Prankl, 0.: Arch. f. Gynik. 93: 649, 1911. (22) 11. Jmc76ke: Ztschr. f. Geburtsh. u. Gynlk. 69: 77, 1911. (23) Kiistner: Ztschr. f. Geburtsh. u. GynLk. SO: 666, 1918. (24) Btiibler: Zentralbl. f. Gyniik. 26: 1068, 1923. (25) Stztfler: Lucina Bologna 10: 151, 1904. (26) Cundelet: Bull. Sot. Anat. 13: 392, 1868. (27) PE’an: Kyste interstitiel des parvis de l’ut&us, LeCons de Cbnique Chirurgicals. T. 111, p. 980 (and Mercade). (25) Wolff, E.: Ztschr. Path. 35: 441, 1927. (29) Merood&, S.: Kystes et Absces de l’uterus, These de Paris, 1905-1906. (30j Bman,a, J. A. : iiher Neubildungen der cervical Portion des Uterus, Miinchen, 1892.

CERVICAL

CARCINOMA

IN A GIRL

DAVID B. LUDWIG, (From

the

Department

of

Gyn.ecology,

M.D.,

OF SIXTEEN

PITTSBURGH,

@olwvtbia

Hospital,

YEARS”

P.4. Wilkinsbwrg,

Pa.)

T

HE literature on this subject discloses a very small number of patients below twenty years of age with carcinoma of the cervix, especially if there has been no pregnancy. The percentage of cases of carcinoma of t.he cervix in nulliparous women is variously given as 2 to 8 per cent. In studying the reports of carcinoma of the cervix in patients of twenty years of age or younger, and especially in children, various authors question the diagnosis of carcinoma, in many cases considering the growth as a teratoma or sarcoma rather than carcinoma. The literature was reviewed by Bonner in 1927, Norse in 1930, and Baldwin in 1931, with report of a case by Xonner and one by Morse. During the forty-eight years which these reviews covered, there were report,ed but six authentic cases of carcinoma of the cervix in individuals between the ages of sixteen months and fourteen years and 7 cases between the ages of sixteen and twenty years. The patient, white, aged sixteen, was referred to me by her family physician Jan. 7, 1930. For six months there had been a dark brown bloody vaginal discharge that was present almost constantly though scant in amount. There had been slight pain in the lower abdomen and pelvis and some burning in the vagina. *Head April

at a Meeting 8, 1936.

of

the

Pittsburgh

Obstetrical

and

Gynecological

Society

held

at, intervals uf thirty to 1:hirtv Tll? menses began at. the age of eleven, The flow wkils not, excessiv e at tlays, 1and continued for four or five days. increase in the past six mmths. Some pain time, 1nit there had been a slight the first day, yet she was never contined in bed. experit mxd

Fig.

1. --l,ow-power

Fig.

2. -High-power nuclei,

photomicrograph and the sparse

showing glandular fibrous supportive

field of the tumor revealing multiple large nucleoli, and

formation st~onla.

rounded atypical

cells mitotic

of the

with large flgures.

nrcujl

vesi< XllU

The patient had itiuenza at the age of nine years tilt made a goad reco very. She ha td always had good health, and there was no histor,y of chronic or Imalig nant $8 in her family. The patient was well developed and well nourisl led. Her

538

AMERICAN

JOURNAL

OF

OUSTETRICS

ASD

GYKECOLOGY

weight was IL’S pountls and her height, was 5 fric,t 5 in~shc% Hllr (lid nut know of any loss of mcight since the bcginuing of the blec’tliug. 11~ c&r was fairly good. The abdomen was not distende,d. Palpation ~\e:tletl tenderness but no mass was demonstrable. B.H.C. 3,9OO,OiM, W.B.C. per cent. The Wassermann test was negative. Though vaginal examination at the tissue from a soft friable intravaginal examination was made by Vandergrift carcinoma of the cervix.

just above the pubes, 9,500, and Hb. 76

oftic!e was unsatisfactory, several growth mere secured. The who diagnosed the condition

pieces

of

pathologic as adeno-

The patient was admitted to the Columbia Hospital Jan. 8, 1930. Vaginal examination, under anesthesia, was done the following day. A soft, friable mass filled the upper half of the vagina, and the entire circumference of the cervix was involved, the right side to a greater extent than the left. The portion of the growth of the left side was rirmer than that of the right side. Upon manipulation the mass bled considerably. The uterus was a little enlarged and situated in the long axis of the body. The tubes and ovaries were not palpatted. The cervical opening was dilated and the Operation was performed as follows: uterus curetted. No eurettings were obtaineql. Three portions of tissue were removed from the cervical growth for laboratory examination, following which the remainder of the cervix was amputated by cautery. At this time 3160 mg. hours of radium were used. X-ray treatment ww instituted three weeks later at the Westmoreland County Hospitsl. Pathologic report by Dr. Vandergrift:-The sections showed a fibromuscular structure with epithelial masses invading one sitle. The cells were large, and vesicular nuclei were arrangetl in small masses. Some of these masses were isolated in the fibromuscular tissue. 0thcl.s showed numerous massed columnar glandlike structures with only a very scan’t stroma and a few capillaries. These glandlike structures were not definitely outlined and the cells were not arranged in an orderly manner. Many mitotic figures were seen. Uiaglzosis: Adenocarcinoma of cervix. A section of this specimen was also esaminprl by Dr. H:t.ythorn at the Singer Memorial

Laboratory.

Five months later the patient received 1123 mg. hours of radium application and following that she was reexamined at intervals of two or three months for the next eighteen months. Nine months after the operation there was slight bleeding from the vagina following examination, but there was no evidence of recurrence of the growth. Eighteen months after the operation the patient complained of some Examination revealed a small reddened area on the discomfort in the rectum. anterior aspect of the rectum about an inch from the anal orifice. Subsequent examination at a later date sho~ved no evidence of any inflammatory process of the rectum

but

there

was

some

perianal

pruritis.

The second year after operation the patient had a moderately severe attack of cystitis and pyelitis on the left side, wh~11 lasted intermittently for two months. Six months later another attack of cystitis developed, which was mild and of short The patient reported for reexamination every three to six months during duration. the years 1932, 1933, and 1934. Xay 27, 1923, there was a slight amount of nonsanguinous mucoid discharge from the vagina. The uterus was normal in size and There was induration along the left broad ligament and a was partially fixed. lesser amount of induration posterior to the uterus. The inflammatory process was .July 4, 1933, menstrual periods were requite well absorbed within three months. sumed, occurring every twenty-eight days, nit11 excessive bleeding on two occasions, Two periods were prolonged.

The patient% last visit was on Feb. D pi, 193.3, :t litt.le over fivr years sinW trWLtlllt!lli~ OIL She weighed 151 pounds,ant1 nppearecl in excellent health. was instituted. examination the uterus was found to be small. There was some constriction ot’ t,he left vaginal Vault and slight induration to the left am1 ~:~ostcriorlg. The patient. reported that there was some prolongation of the menstrual period in January, 7P:G. hut that the total amount wgs not excg:ssi\ t’.

1. The paucity of cases among earlier author? and th!? increasing number r(‘ported at the present time empijmsixcs the nrrrssity for more prumpt retogrlititrtl and reporting of such cases. 2. Because of the admitted high mortality rate 3P carcinoma cases among tllcl young every available m&hod for thorough treatment VW t~ploycd. ::. The amount of the initial dose of r:tGium ntilizrti WLS smxllrr bec:?ust> ol tile anatomic proximity of the bladder, uMhra, 2nd rectum. With this in mind tllr danger of an ensuing fistu1.a betwe~~n thc?c strn0urcr an11 tl:c vagina had to 1~ ~sou sjdwwl. RFPPRFU(‘E’S , ‘
AX.

J. OHST.

520, 1930.

CHORIOMA

,.

& GYSF:C.

I-4:

li5,

(3) Rrk7t~i~~, L. G.:

(CHOR.IOADENOMA

JOSEPH J. MUNDELL,

ND.,

1937. (3) J. OBST.

411.

Xorse: $ GYMW.

ASI. 21:

TYPE)”

Wasm~:~os,

D. C.

M

RS. T., aged twenty-five years, marriell live years, never pregnant. Nenses were always irregular, usually ever,v thirty-five (lags but often missing one or two months, occasionally three or four months. ~rescnt illness.--Last norm++1 menstruation began May 0, 1931. Beginning .1nnc YJ there was a scant light brown vaginal spotting following miclurition. Thi.5 recurred for a day or so at a time, every few days. She was put to b(4 on July S hecause of bleeding which increased in amount until July 16, when she aborted. On July 15 an Aschheim-Zondek test was positive. Patient says that on July Iti she passed a sac and that twelve hours later there was a. hemorrhage and the foilowing day she passed a large mass having the appearance of fish roe. Free bleeding in spite of ergot, etc., continued until her admission to Proviilence Hospital, August 17. Examination revealed a soft patulous gaping cervi:p and a slightly enlargrd soft boggy fundus. On August 15 under g&s anesthesia retained secundines were wrnwwl. The pathologic~ reltort, of the moderate amount of material remove,
3935.

at a meetins

of

the

Washin@n

Gynwologid

society,

~~~~~~~~~~~ :’ i,