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Patient presentations: Panel discussion
Patient presentations: Panel discussion*
elevated, friable, circumscribed, pink area remained on the bowel surface. A frozen section from this area revealed papillary adenocarcinoma. Distally, there were two or three additional thickened, slightly granular serosal lesions of the bowel measuring 2 to 3 mm. in diameter, apparently metastatic tumor. These were not biopsied. The opposite tube, both ovaries, and the uterus were normal, as were all other abdominal organs. Bilateral salpingo-oophorectomy and umbilectomy were performed. Due to the metastasis and the patient’s age, it was elected to leave the uterus behind, thus, decreasing the risk of peritoneal infection from the recent cervical conization. Gross and microscopic examination of the surgical specimens revealed the following: both ovaries and the right Fallopian tube were normaI; the isthmic three fourths of the left Fallopian tube was also normal; the fimbriae of the left tube were adherent to each other and one surface of the fimbriated end was raw. The distal 2 cm. of the tube and fimbria were swollen and indurated. Microscopic examination of the left Fallopian tube revealed edematous, orderly fimbria1 mucosa giving way, abruptly, to papillary adenocarcinoma. The tumor extensively invaded the wall of the Fallopian tube and both lymphatic and vascular invasion were prominent. Similar papillary adenocarcinoma was present both in the tissue from the site of tubal attachment to the sigmoid colon and in the umbilicus. The remainder of the surgical material was unremarkable on microscopic examination. Final pathologic diagnosis was papillary adenocarcinoma of left Fallopian tube with extension and/or metastases to the wall of the sigmoid colon and metastases to the umbilicus. On the seventh postoperative day, 25 mcg. of radioactive phosphorus was instilled in the peritoneal cavity. Her entire postoperative course was benign and on June 10, 1968, she was discharged. She then received a course of external cobalt irradiation with a tumor dose of 6,036 r given over a period of 68 days.
Adenocarcinoma of umbilicus secondary to Fallopian tube carcinoma MAIJRICE M.D.,
G.
COUTURIER,
SR.,
F.A.C.S.
RICHARD
C.
NEALE,
JR.,
M.D.,
F.C.A.P. Eden,
North
Carolina
P R I M A R Y carcinoma of the Fallopian tube is infrequent (0.16 to 1.6 per cent of all primary cancer+) when compared to the incidence of other cancers of the female reproductive tract. It poses treatment, detection.
a difficult the latter
problem in diagnosis due principally to its
and late
This 70-year-old, white, married female, para 5-O-O-5, with her last menstrual period at about age 52 with uneventful menopause, complained of a “persistent infection of the umbilicus.” In the umbilicus was a flat, pinkish brown, granuIar lesion, 1.7 cm. in diameter. A Papanicolaou smear was reported as Class V and biopsy revealed papillav adenocarcinoma. The remainder of the physical examination, laboratory studies, and roentgen studies of the gastrointestinal tract, gallbladder, kidneys, and lungs revealed no abnormalities. Pelvic examination was unremarkable with no discharge, tenderness, or abnormal masses. A Papanicolaou smear of the vagina a.nd cervix was reported as Class IV. Cervical conization and endometrial curettage revealed “chronic cervicitis and atrophic endometrium.” At abdominal operation the umbilical lesion was widely excised. The fimbriated end of the left Fallopian tube was found adherent to the sigmoid colon and in its distal end there was an indurated 2 cm. tumor mass. Upon peeling the adherent tube from its attachment to the colon, a 2 cm.,
The finding of a papillary adenocarcinoma, obviously metastatic to the umbilicus, necessitated abdominal exploration. The finding of primary carcinoma of the Fallopian tube was suspected, in spite of the fact that there were no signs or symptoms of this lesion (usually a pelvic mass, bloody or watery discharge, and abdominal pains), because of the positive Papanicolaou smear with a negative curettage and cervical
*Presented by invitation at the Thirtyfirst Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Sfirings, Virginia, Feb. 2-5, 1969. 32
Volume Number
Patient presentations
105 1
33
conization and no evidence of primary cancer ekewhere. The prognosis of patients with primary carcinoma of the Fallopian tube is poor. The present patient is no exception since there were already distant metastases, involvement histologically of lymphatics and veins, and direct extension to the adjacent sigmoid colon. The usual treatment is total hysterectomy, bilateral salpingo-oophorectomy, and due to its frequent metastasis to the vagina, a wide vaginal cuff. Radiation is not of great value. REFERENCES
G. E., and Potter, E. L.: AM. J. 79: 24, 1960. 2. Hurlbutt, F. R., and Nelson, H. B.: Obst. & Gy:nec. 21: 730, 1963.
1. Hayden, OBST.
& GYNEC.
Stromal endometriosis of the uterine body and cervix DONALD
L.
WHITENER,
M.D.
Defiartment of Obstetrics and Gynecology, Bowman Gray School of Medicine, Wake Forest Unioersity, Winston-Salem, North Carolina
ME S E N C H Y M AL tumors resembling the endometrial stroma have been labeled variously stromatosis, stromal endometriosis, endolymphatic stromal myosis, hemangiopericytoma, and endometrial stromal sarcoma. As these descriptive terms suggest, there is uncertainty as to the cell of origin and the behavior of these tumors. This report illustrates the difficulty in correlating the clinical, pathologic, and biologic characteristics of this myometrial lesion. This patient (Mrs. V. Cl., NCBH 15 22 93) was 34 years of age and she had been infertile through 10 years of marriage. She had been examined over a 2 year period because of heavy menstru$ bleeding. Cyclic therapy with an estrogen-progesterone combination had successfully controlled the menorrhagia, and no abnormalities had previously been discovered. On this occasion, the patient reported irregular bleeding for 6 months. Again the menorrhagia had been partly controlled by cyclic use of steroids, but she developed abdominal discomfort and fullness. The past medical history revealed no serious illnesses. Mumps orchitis was the apparent cause
Fig. 1. Stromal endometriosis.
(x400.)
of this couple’s infertility. The patient had had no previous surgery. Physical examination revealed no abnormalities except a soft, nontender mass fiHing the lower abdomen. On pelvic examination, the uterus was found to be enlarged and softened. No separate adnexal masses were felt. The cervix was soft and partly dilated. The hemoglobin was 11.9 Gm. per cent; the hematocrit 38 volumes per cent; the white blood count was 11,000 cells per cubic millimeter. The differential blood count and the urinalysis were normal. An intravenous pyelogram was reported to show a soft tissue mass in the lower abdomen with no calcification; the ureters were displaced laterally by the pelvic mass, and the right ureter and renal pelvis were slightly dilated. A chest film was reported to show the lung fields to be clear. The Warnpole and Gravindex pregnancy tests were negative. At operation the cervix was found to be dilated by a soft, cystic mass in its lower portion. This cystic mass contained serosanguineous fluid, blood, and friable reddish brown tissue. The tissue was sent for immediate study. At laparotomy the large pelvic mass was found to arise from the upper part of the cervix with the fundus of the uterus above the well-encapsulated tumor. The Fallopian tubes and ovaries appeared to be normal. The liver was smooth; no periaortic nodes were felt. The uterus was not adherent to adjacent structures. The uterus, tubes,
elevated, friable, circumscribed, pink area remained on the bowel surface. A frozen section from this area revealed papillary adenocarcinoma. Distally, there were two or three additional thickened, slightly granular serosal lesions of the bowel measuring 2 to 3 mm. in diameter, apparently metastatic tumor. These were not biopsied. The opposite tube, both ovaries, and the uterus were normal, as were all other abdominal organs. Bilateral salpingo-oophorectomy and umbilectomy were performed. Due to the metastasis and the patient’s age, it was elected to leave the uterus behind, thus, decreasing the risk of peritoneal infection from the recent cervical conization. Gross and microscopic examination of the surgical specimens revealed the following: both ovaries and the right Fallopian tube were normaI; the isthmic three fourths of the left Fallopian tube was also normal; the fimbriae of the left tube were adherent to each other and one surface of the fimbriated end was raw. The distal 2 cm. of the tube and fimbria were swollen and indurated. Microscopic examination of the left Fallopian tube revealed edematous, orderly fimbria1 mucosa giving way, abruptly, to papillary adenocarcinoma. The tumor extensively invaded the wall of the Fallopian tube and both lymphatic and vascular invasion were prominent. Similar papillary adenocarcinoma was present both in the tissue from the site of tubal attachment to the sigmoid colon and in the umbilicus. The remainder of the surgical material was unremarkable on microscopic examination. Final pathologic diagnosis was papillary adenocarcinoma of left Fallopian tube with extension and/or metastases to the wall of the sigmoid colon and metastases to the umbilicus. On the seventh postoperative day, 25 mcg. of radioactive phosphorus was instilled in the peritoneal cavity. Her entire postoperative course was benign and on June 10, 1968, she was discharged. She then received a course of external cobalt irradiation with a tumor dose of 6,036 r given over a period of 68 days.
Adenocarcinoma of umbilicus secondary to Fallopian tube carcinoma MAIJRICE M.D.,
G.
COUTURIER,
SR.,
F.A.C.S.
RICHARD
C.
NEALE,
JR.,
M.D.,
F.C.A.P. Eden,
North
Carolina
P R I M A R Y carcinoma of the Fallopian tube is infrequent (0.16 to 1.6 per cent of all primary cancer+) when compared to the incidence of other cancers of the female reproductive tract. It poses treatment, detection.
a difficult the latter
problem in diagnosis due principally to its
and late
This 70-year-old, white, married female, para 5-O-O-5, with her last menstrual period at about age 52 with uneventful menopause, complained of a “persistent infection of the umbilicus.” In the umbilicus was a flat, pinkish brown, granuIar lesion, 1.7 cm. in diameter. A Papanicolaou smear was reported as Class V and biopsy revealed papillav adenocarcinoma. The remainder of the physical examination, laboratory studies, and roentgen studies of the gastrointestinal tract, gallbladder, kidneys, and lungs revealed no abnormalities. Pelvic examination was unremarkable with no discharge, tenderness, or abnormal masses. A Papanicolaou smear of the vagina a.nd cervix was reported as Class IV. Cervical conization and endometrial curettage revealed “chronic cervicitis and atrophic endometrium.” At abdominal operation the umbilical lesion was widely excised. The fimbriated end of the left Fallopian tube was found adherent to the sigmoid colon and in its distal end there was an indurated 2 cm. tumor mass. Upon peeling the adherent tube from its attachment to the colon, a 2 cm.,
The finding of a papillary adenocarcinoma, obviously metastatic to the umbilicus, necessitated abdominal exploration. The finding of primary carcinoma of the Fallopian tube was suspected, in spite of the fact that there were no signs or symptoms of this lesion (usually a pelvic mass, bloody or watery discharge, and abdominal pains), because of the positive Papanicolaou smear with a negative curettage and cervical
*Presented by invitation at the Thirtyfirst Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Sfirings, Virginia, Feb. 2-5, 1969. 32
Volume Number
Patient presentations
105 1
33
conization and no evidence of primary cancer ekewhere. The prognosis of patients with primary carcinoma of the Fallopian tube is poor. The present patient is no exception since there were already distant metastases, involvement histologically of lymphatics and veins, and direct extension to the adjacent sigmoid colon. The usual treatment is total hysterectomy, bilateral salpingo-oophorectomy, and due to its frequent metastasis to the vagina, a wide vaginal cuff. Radiation is not of great value. REFERENCES
G. E., and Potter, E. L.: AM. J. 79: 24, 1960. 2. Hurlbutt, F. R., and Nelson, H. B.: Obst. & Gy:nec. 21: 730, 1963.
1. Hayden, OBST.
& GYNEC.
Stromal endometriosis of the uterine body and cervix DONALD
L.
WHITENER,
M.D.
Defiartment of Obstetrics and Gynecology, Bowman Gray School of Medicine, Wake Forest Unioersity, Winston-Salem, North Carolina
ME S E N C H Y M AL tumors resembling the endometrial stroma have been labeled variously stromatosis, stromal endometriosis, endolymphatic stromal myosis, hemangiopericytoma, and endometrial stromal sarcoma. As these descriptive terms suggest, there is uncertainty as to the cell of origin and the behavior of these tumors. This report illustrates the difficulty in correlating the clinical, pathologic, and biologic characteristics of this myometrial lesion. This patient (Mrs. V. Cl., NCBH 15 22 93) was 34 years of age and she had been infertile through 10 years of marriage. She had been examined over a 2 year period because of heavy menstru$ bleeding. Cyclic therapy with an estrogen-progesterone combination had successfully controlled the menorrhagia, and no abnormalities had previously been discovered. On this occasion, the patient reported irregular bleeding for 6 months. Again the menorrhagia had been partly controlled by cyclic use of steroids, but she developed abdominal discomfort and fullness. The past medical history revealed no serious illnesses. Mumps orchitis was the apparent cause
Fig. 1. Stromal endometriosis.
(x400.)
of this couple’s infertility. The patient had had no previous surgery. Physical examination revealed no abnormalities except a soft, nontender mass fiHing the lower abdomen. On pelvic examination, the uterus was found to be enlarged and softened. No separate adnexal masses were felt. The cervix was soft and partly dilated. The hemoglobin was 11.9 Gm. per cent; the hematocrit 38 volumes per cent; the white blood count was 11,000 cells per cubic millimeter. The differential blood count and the urinalysis were normal. An intravenous pyelogram was reported to show a soft tissue mass in the lower abdomen with no calcification; the ureters were displaced laterally by the pelvic mass, and the right ureter and renal pelvis were slightly dilated. A chest film was reported to show the lung fields to be clear. The Warnpole and Gravindex pregnancy tests were negative. At operation the cervix was found to be dilated by a soft, cystic mass in its lower portion. This cystic mass contained serosanguineous fluid, blood, and friable reddish brown tissue. The tissue was sent for immediate study. At laparotomy the large pelvic mass was found to arise from the upper part of the cervix with the fundus of the uterus above the well-encapsulated tumor. The Fallopian tubes and ovaries appeared to be normal. The liver was smooth; no periaortic nodes were felt. The uterus was not adherent to adjacent structures. The uterus, tubes,