Postmenopausal ovarian carcinoma

POSTMENOPAUSAL

OVARIAN

CARCINOMA

SIMON BRODY, M.D., BROOKLYK, (Prom

the Gynecological

Service

of the Beth

N. Y. Moses

Hospital)

T

HE “silent” ovarian tumor has long been recognized as a great menace in the control of cancer by early recognition and treatment.. The new growth is either discovered accidentally, in the course of a routine pelvic examination, or when the tumor becomes extensive enough to be noticed by the patient or to cause pressure symptoms, at which time it is usually beyond surgical interference. In a discussion of this subject, H. S. Crossenl suggested, among other things, “insist,ence on regular periodic pelvic examinations of patients who ask the physician to assume responsibility in regard to their health. These periodic examinations for silent ovarian carcinoma should be made every six months, instead of once yearly, which was formerly supposed to provide adequate safety.” This is excellent advice. While it may require a great deal of educational propaganda to convince the average private patient as to the importance of such frequent examinations, it should not be difficult to inst,itute such a rout,ine a.mong clinic patients. With a proper follow-up system, the patient can be instructed when to report, and is sent for if she fails to do so. However, even among the members of the medical profession, the importance of these frequent examinations has as yet not been fully realized. Only t,oo frequently a patient is discharged as cured or improved without any instructions to report to the clinic again for further observation. This is especially true of a group of patients with irregular menopausal bleeding. This type of paGent is usually sent in to the hospital for a diagnostic curettage and insertion of radium. If the examination of the curettings fails to reveal any malignancy, a castration dose of radium is applied. The patient may subsequently be seen in the clinic for a few months and, if there are no further complaints, she is discharged as cured with instruct,ions to report in case of any recurrence of bleeding or stainin?. But, the fact tha.t a patient, received radium treatment for benign menopausal bleeding does not insure her against the development of other pelvic pathology even in the absence of bleeding. This was brought out by Pemberton’ who, in a series of 86 cases of postmenopausal ovarian malignancy, described two patients who had previously received radium for benign menopausal bleeding. Neither of these patients had any palpable ovarian pathology at the time she was treated with radium. It was in order to further emphasize this point that it was deemed advisable to report the following case. Case Report M. R., a 56-year-old white female, was admitted to the Beth Moses Hospital on April 21, 1941, complaining of irregular vaginal staining and bleeding for the past two months. There were also occasional attacks of dizziness and a loss of eight pounds in weight. Menses started at the age of 13, occurring every 28 to 31 days and lasting 4 to 5 days. The patient had two stillbirths, one of 7 months’ 417

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arstation 30 vears previously, i3llfi one of 8 luoIltlls’ gestaticm X8 years ago. She haa one normal l)regnancy and delivery at term 36 years ago. Iler last menstrual period was th t*ce years ago. l’herc \vAs 11;)staining w bleeding until the time of her present illness. Abdominal esamination did trot rclveal ally rigidity, tenderness or palpable masses. Vaginal csaminution showed a multiparous outlet. The cervix was hard, lacerated, eroded. not friable and freely movablr. The uterus was slightly enlarged, ant,eoerted and deviated to the lefl, movable and not tender. The adnexa could not be palpated. a diagnosis of possible malignancy of the COJ*[~S u&i was ~unde and a diagnostic curettage was advised. This was done on April 22, 194 I. Only a, small amount of tissue was obtained in spite of thorough curettement . The pathologic report w-as that of shreds of endometrilim and myometrium with no evidence of malignancy. The patient was disc.harged from the hospital at the end of a week. The bleeding and staining persisted and t,he patient was readmitted to the hospit,al on September 8, 1941. The vaginal findings were the same as on her previous admission. Another curettage was performed and 50 mg. of radium were inserted in the uterine cavity. The pathologic diagnosis of the curettings was that of cervical epitheliurll md myometrium. There was no evidence of malignancy. The patient received 1,950 millicurie hours of ratlium. She left t,he liuspital on September 21, 1941, in yootl c*onclitiorl. There was no fut,ther bleeding or staining and after the third monthly visit to the clinic+. the patient was told to report only in t*ase of ally further complaints. During May, 1942, the patient \\-a~ readmittetl to the hospital for an hemorrhoidectomy. A vaginal checkup at the time disclosed a hard lacerated cervix, a small uterus. frtle!y mova,blr. The atlncxa could not he palpated. The patient was not seen again unt,il February, 1944, when she returned to the gynecologic clinic complaining of pain in the left side of the lower abdomen for the past six weeks. The pain was constant, dull in cha,racter, radiating down the left, thigh and leg. She suffered from frequent and urgent micturition. She was constipated and felt bloated. There was no loss of weight. Abdominal examination showed the presence of a moderate distension but there was no ericlence of fluid. An irregular, fixed mass conld he felt above the symphysis, apparentI,\ arising from the pelvis. Vaginal examination revealed t,he presence of a hart1 mass filling the region of the left fornix and the posterior caul-de-sac. The cervix was hard, closed and moTable. The uterus could not be felt separately from t,he mass. The right aclnt~xus ~vas hard and thickened, A diagnosis uf pelvic malignancy was mtdc with the possibility of intestinal malignancy to be excludetl. She was at{lnibted to t.he hospital on March 2, 1944. -4 radiographic st,ucly of thr colon by means of a barium enema showed a spastic sigmoid with a soft t,issue mass in t,he pelvis, which appeared extracolic. The patient’s blood pressnac \vas 130/90. The hemoglobin \vas 1:: mp. per 100 C.C.of blood. l-led blood cells were 5,190,OOO;white blood cells 19,000; polymorphonncleal. leucocytes 72 per cent; lymphocytes 28 per cent. Blood Wassermann and Kahn t,ests were negative. BlOod sugar was 90 mg., and urea nitrogen was 1.5nlg. per 100 C.C.of blood. Itepeated examinations of the urine were essentially negatiT.e. On March 6, 1944, a laparot,omy was perfornled under spinal anesthesia. Upon opening the peritoneal cavity the following was noted :

BRODB

:

POSTMESOP.4ITSAI~

OVARIAS

419

C.ZRCISOM.4

There was a mass, the size of a grapefruit in the left side of the pelvis, firmly adherent to the omentum, sigmoid and pelvic floor. This mass seemed to include the uterus and ovary. neither of which could be separately identified. The right ovary was enla.rged, adherent to the intestines and posterior layer of the broad ligament and contained serosanguineous fluid. A supracervical hysterectomy and bilateral salpingooophorectomy were performed. The following were the pathologic findings of the specimen, as described by Dr. A. R. Kantrowitz:

Fig.

l.-Gross to

specimen showing the large left

Fig. L-Section of left by cuboidal to polyhedral alant cells. (X7.5.)

ovary cells

body ovarian

of the uterus in mass, and smaller

the

consisting showing

of papillary and glandular structures, marked atypism with numerous mitoses

right

center, flmmly ovary.

adherent

lined and

(:~oss.-Sltecilllen consists of a nupracervically amputated uterus, tog,rclther with both tubes and ovarirs. The uterus is hound hy dense adhesions to a large left o\a rian nia,ss. The uterus measures 6 by 7 hy 5 (‘Rl. The surface is tnarkcdl~ roughenetl by the presence uf numerous cdonnective tissue ta hs. The uterus is considerably distorted because of the presence of numerous lllasses situated within all locabions. The entlometrial cavity c*iillnot he probed. (‘ross section reveals chocolatebrown tissue rrplacinq the cavity complrtely. except in out small area at the left fundus. The right tube measures 10 cm. ilk Icngth ; its fimhriated end is I)atc*lrt. The ovary is enlarged and measures 7 I,- 3 1)~ 3.5 cm. The surfa~ of the right tube and ovary is covered with very dense adhesions.

The left ovarian mass measures !f cm. in diameter. The entire mass consists of yellow tissue pl,esenting a necrotic appearance. It is bound hy dense adhesions to the uterus, the wall of which is invaded 1)~ th(h yellow amorphous tissue at the area of attachment. lilicroscopic.-The cndomctrinm is atrophic and the cavity, in its greaicst, extent,, is replaced by scar tissue wit,11 pigment-laden macro&ages. The myometrium is invaded 1)~ nests of atypical polyhedral cells in ;I few areas. The left ovarian mass consists of papillar;\; and glandular strucbres lined by cuboidal t,o polyhedral cells showmg marked atypism with numerous mitoses and giant. cells. The greater portion of the mass is completely necrotic. Thr crst locules are lined 1)~ si&lar cells. The right ovary contains nests of’ identical cells. Diagnosis : Bilateral papillary cystadenocarcinoma of the ovaries with extension to the uterus. Status after radiation of the uterus: Ohlit,eration of the endometrial cavity: myomat;l of the nterns.

The patient made an uneventful recovery except for a complicating cystitis. This condition responded to sulfonamide therapy and bladder irrigations. She was discharged from the hospital ou Narch 31, 1944, in good condition.

Fig.

J.-High

power

of section

of uterus polyhedral

showing invasion cells. (X335.)

of myometrium

by atypical

Comment This ease presents a few interesting points worthy of note. The cast.rating dose of radium, which was given to the patient in order to suppress the activity of the ovaries and secondarily eliminate their proliferating influence upon the endomctrium, had its desired effect. This is evidenced by the atrophy and almost complete absence of the endometrium as shown in the specimen removed, and by the cessation of bleeding, clinically. However, the irradiation had no inhibiting It is effect, upon the later development of a neoplasm in these ovaries. important to hear in mind the possibility of such a consequence in a postmenopausal patient who had received radium treatment for bleeding and is apparent,ly cured. Such patients, as well as others under observation, should be examined at frequent, regular intervals for any pelvic pathology. Had the patient reported here been examined more frequently, the growth may have been discovered before it became so big, adherent to the adjacent tissues, and extended into the uterus. Surgery would have been resort,etl to at an earlier stage with the prob ability of a better prognosis.

References 1. Crossen, H. S.: J. A. M. A. 119: 1455, 2. Pemberton, Frank A.: Ax. J. OBST.

1943. & GYNEC.

40:

751,

19411