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Adenoacanthoma with ovarian metastases
512
AMERICAN
JOURNAL
OF
OBSTETRICS
,\XI)
GYSECOI,OG\
found shock. Forty-four (27.5 per cent, ) reqni wd transfusions Iwt’or~~. during, or immediately following delivery. Sixty-seven per rent ncrc delivcrctl I);- CWill'?il?l sect ion. Ill (he fi I’S1 few years the classical sclction was commonly pc~rformrd, Irut. sincsc 1935 the transverse types of laporatrac~l~eloto~~~~ has hcen utilized m~rrc and more. Braxton Hicks’ version was used only in oIlc’ case in which t11~ c~hiltl was not viable. The Witlet.ts clamp was never nsed. The gross maternal morbidity was 37.5 per cc>nt, and the unc~~rrcctcci fetal mortality was 25 per cent, and there were two maternat deaths (1.25 per cent). 0105
Ram
AiDELBERT
ADEr\jOAC:ANTHOMA (‘TAYTOS
‘I’.
WITH B.S., Ml).,
BEECELUI,
()VARIAN
l~sl) IZ~-l~eH~r 11.
PHILADEI,PHI.\, (From
the
Ilrptrtmcnt
of
Oh,strfrics
nari
METASTASEs FRIIUU,
R.,1.,
nl.1).
I’.\. ~~~ynrc:o/o,c~~~,
Tfmplv
l~rriwrsitg
Hospltftlj
UENOCARCINOMA of the fundus with squamons ccl1 met aplasia is not uncommon. Miller’ found it A Novak* states that it is occasionally SW~. Thea phenomc~non is not in
15 pm’
cent
of his
vases,
whilt,
cle:~rI~-
understood but Novak accepts the origin as from “indiffcreni ” ~11s idpossessing a differentiating potenq- which under certain poncditiorls can lead to the formation of a squamous type epithelium.” The occurrence of ovarian metastases with fnndal carcinoma is tmcommon. However, Barnes” found it in 7.4 per cent of his cases, Norris and Vogt4 in 1.7 per cent, and Novak” in 4.8 1~1’ cent. RLore uncommon is the appearance in the ovarian metastases, of metaplastie clrmcnts with keratin formation. The only other case w have been able to find is the one reported by Schattenherg and Ziskintl,’ which was ;I (‘ill’advanced growth. The prognosis in adenoacanthoma is apparently little influencctl b?its strange pathologic picture, although Meigs” does not, agree in this. The prognosis with ovarian mctast ascs. if nof Imwwt t~lsewhew. sholdd be good. The general lack of appreciation that early carcinoma of’ the I’undus can and does metastasize to the ovary should he a warning to I hoso who advocate only radiation therapy. H. S., a married, white, multipara, (C. T. B.) office on Jan. 16, 1942, with charge. Her family history revcalcd died of “cancer of t,hc bowel. ’ Her Onset of catamenia was at 12 years cycle, lasting five days. She had had terminated wit,h forceps cleliveries at
aged .‘,O years, first came to mc a chief complaint of vaginal disthat :I brother and a sister had past history was not significant. of age, wit-h a twentv-eight-da> two pregnancies (last, in 1922): term. Five yreaw ago ( 1937)
BEECHAM
AND
FRIDAY
:
ADENOACANTHOMA
WITH
OVARIAN
METASTASES
513
patient began having hot flushes and insomnia, associated with grossly irregular periods. One and one-half years ago she began to spot every day with never anything suggesting a menstrual period. This bleeding stopped in October, 1941, and since then patient had noticed a profuse, serous, malodorous discharge. There was no bleeding of any kind after October, 1941. Physical examination was essentially negative. Pelvic examination revealed only a small nodule (3 cm.) at the left cornu of the uterus. This we believed was a myoma. Jan. 19, 1942: Admitted to Temple University Hospital and a curettage was done. Uterine cavity was found to be three inches deep. -4bundant pinkish gray tissue was obtained.
Fig.
1.-(33,521X) Note
how
High power the squanmus
photomicrograph cells almost
All
of the
section lumen
of
from uterine curettings. several glmds.
Microscopic examination (Dr. R. H. E’riday) : “The uterine curettings show a marked hyperplasia of the glandular elements with 10~3 of the normal pattern and secondary acinar formation. The cells lining the glands arc three to four layers deep. They are pleomorphic and hyperchromatic, and in some areas form cordlikc projections. There is quite extensive squamous cell metaplasia in some areas, giving the picture of adenoacanthoma. ’ ’ Diapwsis : Aclenocarcinoma, Grade II, with squamous cell metaIjlasia. ” Jan. 21. 1942: Under spinal anesthesia, the abdomen was opened in the midline. The uterus was normal in size, shape, and position, except for one small fibroid. What we had thought was a cornual fibroid proved to be the left ovary which was cystic in part and also demonstrated a hard indurated portion with macular projections from its surface. A radical panhysterectomy and bilateral salpingo-oophorectom> were done. The iliac vessels were exposed and a search made for lymph
514
AMERICAN
Fig. 2.-(33544.) High r~rrinomn and squamous type.
JOIJRNAL
OF
OBSTETRICS
Power. Section taken from epithelium which is highly
ASI)
GYNECOLOGP
the left ovary. diffwrntiaterl
showing atlem~into the xrlult
REECHAM
AKD
FRIDAT
:
ADENOACASTHOMA
WITH
OVARIAN
METASTASES
515
uterus is 6 by 8 cm. Its contour is smooth, except for a small fibroid tumor in the fundal wall. The myometrium is 1 cm. thick. The endometrium is shaggy, granular and hemorrhagic, and thickest at the fundic portion. The growth of cndomctrium extends to the internal OS. The cervix appears normal. The left ovary is cystic and measures 4 cm. in diameter. On the surface there is a small cauliflowerlike projection which feels like keratin. The cyst lining contains several macular projections of similar appearance. The oppayite ovary is small and sclerotic. The tubes are grossly normal. “Microscopic Ex~~~inalion.-The sections through the endometrium showed a similar picture as the curettings. There is malignant growth of the glands with invasion of the myometrium to the depth of 3 mm. There is piling up of the epithelium and acinar formation. “The cervix shows a chronic inflammatory reaction. The predominating infiltrating cell is the lymphocyte. The sections from the left ovary present a curious picture of metastatic adenocarcinoma, with marked squamous cell metaplasia. There is stratification and keratin formation. There is invasion throughout the wall of the cyst. The cells. have all the characteristics of malignancy. “Sections from the left tube show a moderate lymphocytic infiltrat,ion and fibrosis of the wall. No tumor cells are visualized. “Dtignosis: adenocarcinoma of corpus uteri ; metastatic adenocarcinema to left ovary ; chronic salpingitis (mild). ” DISCUSSION
This case of adenocarcinoma of the fundus with squamous cell metaplasia is of interest for several reasons. First, that we have a fairly early, low-grade malignancy demonstrating ovarian metastases. Second, we have found only one other case (Schatt,enberg and Ziskind) where metaplasia spread to the ovary and produced keratin. Third, the hopeless prognosis this case would have, had we chosen to use only radiation as some clinics propose. Fourth, this case is in keeping with Novak’s statement that squamous cell metaplasia occurs “in adenocarcinoma of the lesser degrees of malignancy.” REFERENCES 1. Miller, 2. Novak, 3. 4. 5. 6.
N. F.: AM. J. OBST. & GY;NEC. 44: 793, 1940. E.: Gynecological and Obstetrical Pathology, Philadelphia, B. Saunders Co., pp. 202. Barnes, H. H. F.: J. Obst. & Gynaec. Brit. Emp. 48: 443, 1941. Norris, C. C., and Vogt, M. C.: AK J. OBST. & GYNEC. 7: 550,1924. Schattenberg, H. J., and Ziskind, J.: AM. J. OBST. Cp- GYNEC. 39: 112, Meigs, J. V.: Tumors of the Female Pelvic Organs, New York, MacMillan Co., pp. 140. 5123
WAYNE
AVENUE
1940,
1949. 1934,
W.
The
AMERICAN
JOURNAL
OF
OBSTETRICS
,\XI)
GYSECOI,OG\
found shock. Forty-four (27.5 per cent, ) reqni wd transfusions Iwt’or~~. during, or immediately following delivery. Sixty-seven per rent ncrc delivcrctl I);- CWill'?il?l sect ion. Ill (he fi I’S1 few years the classical sclction was commonly pc~rformrd, Irut. sincsc 1935 the transverse types of laporatrac~l~eloto~~~~ has hcen utilized m~rrc and more. Braxton Hicks’ version was used only in oIlc’ case in which t11~ c~hiltl was not viable. The Witlet.ts clamp was never nsed. The gross maternal morbidity was 37.5 per cc>nt, and the unc~~rrcctcci fetal mortality was 25 per cent, and there were two maternat deaths (1.25 per cent). 0105
Ram
AiDELBERT
ADEr\jOAC:ANTHOMA (‘TAYTOS
‘I’.
WITH B.S., Ml).,
BEECELUI,
()VARIAN
l~sl) IZ~-l~eH~r 11.
PHILADEI,PHI.\, (From
the
Ilrptrtmcnt
of
Oh,strfrics
nari
METASTASEs FRIIUU,
R.,1.,
nl.1).
I’.\. ~~~ynrc:o/o,c~~~,
Tfmplv
l~rriwrsitg
Hospltftlj
UENOCARCINOMA of the fundus with squamons ccl1 met aplasia is not uncommon. Miller’ found it A Novak* states that it is occasionally SW~. Thea phenomc~non is not in
15 pm’
cent
of his
vases,
whilt,
cle:~rI~-
understood but Novak accepts the origin as from “indiffcreni ” ~11s idpossessing a differentiating potenq- which under certain poncditiorls can lead to the formation of a squamous type epithelium.” The occurrence of ovarian metastases with fnndal carcinoma is tmcommon. However, Barnes” found it in 7.4 per cent of his cases, Norris and Vogt4 in 1.7 per cent, and Novak” in 4.8 1~1’ cent. RLore uncommon is the appearance in the ovarian metastases, of metaplastie clrmcnts with keratin formation. The only other case w have been able to find is the one reported by Schattenherg and Ziskintl,’ which was ;I (‘ill’advanced growth. The prognosis in adenoacanthoma is apparently little influencctl b?its strange pathologic picture, although Meigs” does not, agree in this. The prognosis with ovarian mctast ascs. if nof Imwwt t~lsewhew. sholdd be good. The general lack of appreciation that early carcinoma of’ the I’undus can and does metastasize to the ovary should he a warning to I hoso who advocate only radiation therapy. H. S., a married, white, multipara, (C. T. B.) office on Jan. 16, 1942, with charge. Her family history revcalcd died of “cancer of t,hc bowel. ’ Her Onset of catamenia was at 12 years cycle, lasting five days. She had had terminated wit,h forceps cleliveries at
aged .‘,O years, first came to mc a chief complaint of vaginal disthat :I brother and a sister had past history was not significant. of age, wit-h a twentv-eight-da> two pregnancies (last, in 1922): term. Five yreaw ago ( 1937)
BEECHAM
AND
FRIDAY
:
ADENOACANTHOMA
WITH
OVARIAN
METASTASES
513
patient began having hot flushes and insomnia, associated with grossly irregular periods. One and one-half years ago she began to spot every day with never anything suggesting a menstrual period. This bleeding stopped in October, 1941, and since then patient had noticed a profuse, serous, malodorous discharge. There was no bleeding of any kind after October, 1941. Physical examination was essentially negative. Pelvic examination revealed only a small nodule (3 cm.) at the left cornu of the uterus. This we believed was a myoma. Jan. 19, 1942: Admitted to Temple University Hospital and a curettage was done. Uterine cavity was found to be three inches deep. -4bundant pinkish gray tissue was obtained.
Fig.
1.-(33,521X) Note
how
High power the squanmus
photomicrograph cells almost
All
of the
section lumen
of
from uterine curettings. several glmds.
Microscopic examination (Dr. R. H. E’riday) : “The uterine curettings show a marked hyperplasia of the glandular elements with 10~3 of the normal pattern and secondary acinar formation. The cells lining the glands arc three to four layers deep. They are pleomorphic and hyperchromatic, and in some areas form cordlikc projections. There is quite extensive squamous cell metaplasia in some areas, giving the picture of adenoacanthoma. ’ ’ Diapwsis : Aclenocarcinoma, Grade II, with squamous cell metaIjlasia. ” Jan. 21. 1942: Under spinal anesthesia, the abdomen was opened in the midline. The uterus was normal in size, shape, and position, except for one small fibroid. What we had thought was a cornual fibroid proved to be the left ovary which was cystic in part and also demonstrated a hard indurated portion with macular projections from its surface. A radical panhysterectomy and bilateral salpingo-oophorectom> were done. The iliac vessels were exposed and a search made for lymph
514
AMERICAN
Fig. 2.-(33544.) High r~rrinomn and squamous type.
JOIJRNAL
OF
OBSTETRICS
Power. Section taken from epithelium which is highly
ASI)
GYNECOLOGP
the left ovary. diffwrntiaterl
showing atlem~into the xrlult
REECHAM
AKD
FRIDAT
:
ADENOACASTHOMA
WITH
OVARIAN
METASTASES
515
uterus is 6 by 8 cm. Its contour is smooth, except for a small fibroid tumor in the fundal wall. The myometrium is 1 cm. thick. The endometrium is shaggy, granular and hemorrhagic, and thickest at the fundic portion. The growth of cndomctrium extends to the internal OS. The cervix appears normal. The left ovary is cystic and measures 4 cm. in diameter. On the surface there is a small cauliflowerlike projection which feels like keratin. The cyst lining contains several macular projections of similar appearance. The oppayite ovary is small and sclerotic. The tubes are grossly normal. “Microscopic Ex~~~inalion.-The sections through the endometrium showed a similar picture as the curettings. There is malignant growth of the glands with invasion of the myometrium to the depth of 3 mm. There is piling up of the epithelium and acinar formation. “The cervix shows a chronic inflammatory reaction. The predominating infiltrating cell is the lymphocyte. The sections from the left ovary present a curious picture of metastatic adenocarcinoma, with marked squamous cell metaplasia. There is stratification and keratin formation. There is invasion throughout the wall of the cyst. The cells. have all the characteristics of malignancy. “Sections from the left tube show a moderate lymphocytic infiltrat,ion and fibrosis of the wall. No tumor cells are visualized. “Dtignosis: adenocarcinoma of corpus uteri ; metastatic adenocarcinema to left ovary ; chronic salpingitis (mild). ” DISCUSSION
This case of adenocarcinoma of the fundus with squamous cell metaplasia is of interest for several reasons. First, that we have a fairly early, low-grade malignancy demonstrating ovarian metastases. Second, we have found only one other case (Schatt,enberg and Ziskind) where metaplasia spread to the ovary and produced keratin. Third, the hopeless prognosis this case would have, had we chosen to use only radiation as some clinics propose. Fourth, this case is in keeping with Novak’s statement that squamous cell metaplasia occurs “in adenocarcinoma of the lesser degrees of malignancy.” REFERENCES 1. Miller, 2. Novak, 3. 4. 5. 6.
N. F.: AM. J. OBST. & GY;NEC. 44: 793, 1940. E.: Gynecological and Obstetrical Pathology, Philadelphia, B. Saunders Co., pp. 202. Barnes, H. H. F.: J. Obst. & Gynaec. Brit. Emp. 48: 443, 1941. Norris, C. C., and Vogt, M. C.: AK J. OBST. & GYNEC. 7: 550,1924. Schattenberg, H. J., and Ziskind, J.: AM. J. OBST. Cp- GYNEC. 39: 112, Meigs, J. V.: Tumors of the Female Pelvic Organs, New York, MacMillan Co., pp. 140. 5123
WAYNE
AVENUE
1940,
1949. 1934,
W.
The