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Adenocarcinoma of endometriosis of the ovary: A case report
Volume Number
110 6
Patient
ovarian enlargement Total abdominal hysterectomy and bilateral salpingo-oophorectomy were carried out on the twelfth of October. Findings at operation revealed a uterus within normal limits of size with several small serosal fibroids over the posterior aspect of the fundus. A 7 to 8 cm. solid ovarian tumor was found, involving the right ovary. It was adherent at one area to the posterior portion of the right broad ligament, and there was extension of the tumor to the right lateral pelvic wall. Fluid was present in the peritoneal cavity. The left adnexal structures appeared grossly normal. Pathology report described the right ovary as a mass measuring 7 by 5 by 6 cm.; cut surface was gray-yellow and firm with scattered cystic spaces. On microscopic examination, a diagnosis of granulosa cell carcinoma of the right ovary and cystic hyperplasia of the endometrium was made. Thio-Tepa, 15 mg., in 20 C.C. of saline was instilled in the pelvic cavity following reperitonealization of the pelvis. Because of the dissection of the patient’s tumor from the right lateral pelvic wall close to the right ureter, an intravenous pyelogram was done on her seventh postoperative day which revealed good function with no apparent obstruction of either ureter. The patient’s postoperative recovery was remarkably uneventful, and she was discharged on her seventh postoperative day. The patient was examined by us monthly for three months following operation and then by her family physician and a gynecologist in another city in Florida. In January, 1971, she was asymptomatic, and the physical and pelvic examinations were negative. Cytology was again reported Class 1 with estrogenic corn&cation of 30 per cent. In summary, this patient in whom definitive operation for adenomatous hyperplasia of the endometrium was delayed was found to have an associated estrogen-producing ovarian neoplasm. The clinical discovery of the patient’s ovarian tumor occurred two years after the diagnosis of adenomatous hyperplasia of the endometrinm was made. In addition to the possible developnlent of endometrial malignancy, the .occurrence of an estrogen-producing tumor of the ovary, though rare, should be considered when planning treatment for the patient with the diagnosis of adenomatous hyperplasia of the endometrium.
Adenocarcinoma of endometriosis of the ovary: A case report EDWARD Greensboro,
B. MABRY, North
M.D.
Carolina
THERE ARE THREE ASPECTS of this report that seem noteworthy: (1) The occurrence of adenocarcinoma in ovarian endometrioPresented by invitation at the Thirty-third Annual ing of the South Atlantic Association of Obstetricians ~~yneco~ogists, Atlanta, Georgia, February 7-10, 1971.
Meetand
presentation
783
sis is rare; (2) the pathogenesis of adenocarrinoma of the ovary may not always be the same; (3) the treatment may vary depending upon the pathogenesis. Sampson,l in 1925, described the eticllogy, pathogenesis, and criteria for diagnosis of this lesion. During the last fifteen to twenty years, more attention has been given to this problfmz-s The efficacy of treating uterine adenocarcinoma with high doses of progesterone has been reported by several investigators. 6-s This discovery led to further consideration of the use of high doses of progesterone in the treatment of carcinoma arising from ovarian endometriosis. A 25-year-old Caucasian married woman, para 0, complained of infertility. She was first examined on August 26, 1969. She had been married for five years and had used no contraception for the two immediately preceding years. Prior to the last two years, she had been taking a sequential contraceptive agent. Her periods had always been regular and normal. Menarche occurred at age 11; she had bled every twenty-eight to thirty days, and the amount of bleeding was constant and predictable, the flow lasting about five days. She had never complained of excessive dysmenorrhea. Her general health had been good. A tonsillectomy had been performed when she was a child. Prior to her marriage, she had a ruptured ovarian cyst, but operation was not performed. She was told in 1967 by her family physician that she had another cyst on her ovary. Examination revealed a well-developed, wellnourished Caucasian woman. The general physical examination and laboratory studies were normal. On pelvic examination, the external genitals, hair, skin, Bartholin’s and Skene’s glands, clitoris, and urethra were normal. The vagina was clean. The cervix was clean, nulliparous, and in mid-pcasition. The uterus was of normal size and slightly anteflexed. The uterine cavity was sounded 2% inches and was anterior. No adnexal masses were palpable. There was no tenderness and no nodularity palpable in the pelvis. Rectovaginal examination confirmed these findings. During the next three to four months, the infertility work-up revealed no abnormalities. On December 12, 1969, a pelvic examination revealed a 4 to 5 cm. right ovarian cyst. The tumor persisted until April, 1970. Operation was performed on April 15, 1970. Extensive endometriosis involved both ovaries and the cul-de-sac. The endometriosis in both ovaries was excised, leaving the uninvolved portion of each ovary. The essential gross pathologic findings were a 2.5 cm. cyst of the right ovary containing brown fluid with a 1 by 1 cm. papillary formation on the lining surface, a 1 cm. firm area, and a 1.5 cm. corpus Iuteum. Microscopically, the cyst was lined by endometrial glands and stroma which in places formed papillary projections into the lumen of the cyst. There was a focus of invasion of ,>varian
784
Patient
presentation
Amer.
stroma. The epithelium showed atypia, and there were many areas of squamous metaplasia. There was a 1 cm. area in which the glands were closely placed with little or no intervening stroma. The cells had hyperchromatic nuclei which varied in size. Mitoses were present. Endometriosis was present in both ovaries. Diagnosis was endometrioid carcinoma (adenoacanthoma pattern) of the right ovary and endometriosis of the right and left ovaries. On May 14, 1970, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. The omentum was grossly normal and was not removed. There was residual endometriosis but no malignancy in any of the tissue. Postoperatively, 500 mg. of medroxyprogesterone acetate* was administered intramuscularly at weekly intervals for the next twelve weeks and then intramuscularly once each month. This medication has been tolerated well, and she has reported no untoward effects. She has remained well, and no tumor is demonstrable. The incidence of this disease is difficult to ascertain. Often, at the time of operation, the extent of carcinoma is so great that no definite link with pre-existing endometriosis can be established. It is possible that, as Dockertys suggests, the incidence of carcinoma arising from endometriosis of the ovary may be much higher than it appears. Sampson1 earlier mentioned this possibility also, and he listed strict criteria necessary to establish that an adenocarcinoma of the ovary arose from endometriosis in that ovary. These criteria were met in this patient. Sampson1 and later Long and Taylor4 as well as others speculated that endometrial tumors might arise directly from ovarian serosa. It seemed reasonable that the embryologic potential of coelomic epithelium could be retained and differentiate into various tissues, including the uterine epithelium. Thus, endometrial tumors of the ovary could arise with no demonstrable evidence of endometriosis. The third facet of the problem is related to treatment. If it is established that this condition arose as a result of ovarian serosal change with differentiation directly into ovarian adenocarcinoma, it would seem reasonable that the usual treatment of adenocarcinoma of the ovary would be appropriate. This would include a surgical procedure and irradiation or chemotherapy, with the use of one of the alkylating agents such as chlorambucil. However, if we determined conclusively that the carcinoma arose primarily from endometriosis in the ovary, then it would seem that the most
‘Depo-Provera, Michigan.
The
Upjohn
Company,
K&unazoo,
July 1.5, IWI J. Obstct. Gynr<
efficacious treatment would be that commonly used to treat adenocarcinoma of the endometrium. In this patient, we believed the evidence supported the latter pathogenesis and treated the patient accordingly. REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Sampson, J. A.: Arch. Surg. 10: 1, 1925. Dockerty, M. B.: AMER. J. OBSTET. GYNEC. 83: 175, 1962. Scully, R. E., Richardson, G. S., and Barlow, J. F.: Clin. Obstet. Gynec. 9: 384, 1966. Long, M. E., and Taylor, H. C.: AMER. J. OBSTET. GYNEC. 90: 936, 1964. Anderson, D. C.: AMER. J. OBSTET. GYNEC. 92: 87, 1965. Kelley, R. M., and Baker, W. H.: Progr. Gynec. 4: 436, 1963. Kistner, R. W.: Cancer 12: 1106, 1959. Varga, A., and Henricksen, E.: Obstet. Gynec. 18: 658, 1961.
Pregnancy in paraplegic Two case reports WILLIAM Richmond,
M. OPPENHIMER, Virginia
patients: M.D.
ACCIDENTS and other diverse forms of trauma have led to an increasing number of paraplegic and quadraplegic women. Relatively little has appeared in the obstetric literature concerning this rather uncommon clinical entity.
AUTOMOBILE
The pregnant spinal cord-injury patient presents certain unusual and difficult problems, such as autonomic dysreflexia, which should be recognized. The following case reports and discussion point up some of these problems and provide a framework for the rational treatment of these unfortunate patients. Case 1. Mrs. M. W. sustained a motor and sensory paraplegia at the levels of the eleventh and twelfth thoracic vertebrae as a result of a fracture dislocation at age 14 while she was horseback riding. Menarche had occurred at age 11, and menses resumed 7 months after the accident at 29 day intervals. Postinjury bladder training was successful. In 1966, at age 35, she conceived after 7 years of marriage and had an uneventful prenatal course.
Presented ing of the Gynecologists,
by invitation at the Thirty-third Annual South Atlantic Association of Obstetricians Atlanta, Georgia, February 7-10, 1971.
Meetand
110 6
Patient
ovarian enlargement Total abdominal hysterectomy and bilateral salpingo-oophorectomy were carried out on the twelfth of October. Findings at operation revealed a uterus within normal limits of size with several small serosal fibroids over the posterior aspect of the fundus. A 7 to 8 cm. solid ovarian tumor was found, involving the right ovary. It was adherent at one area to the posterior portion of the right broad ligament, and there was extension of the tumor to the right lateral pelvic wall. Fluid was present in the peritoneal cavity. The left adnexal structures appeared grossly normal. Pathology report described the right ovary as a mass measuring 7 by 5 by 6 cm.; cut surface was gray-yellow and firm with scattered cystic spaces. On microscopic examination, a diagnosis of granulosa cell carcinoma of the right ovary and cystic hyperplasia of the endometrium was made. Thio-Tepa, 15 mg., in 20 C.C. of saline was instilled in the pelvic cavity following reperitonealization of the pelvis. Because of the dissection of the patient’s tumor from the right lateral pelvic wall close to the right ureter, an intravenous pyelogram was done on her seventh postoperative day which revealed good function with no apparent obstruction of either ureter. The patient’s postoperative recovery was remarkably uneventful, and she was discharged on her seventh postoperative day. The patient was examined by us monthly for three months following operation and then by her family physician and a gynecologist in another city in Florida. In January, 1971, she was asymptomatic, and the physical and pelvic examinations were negative. Cytology was again reported Class 1 with estrogenic corn&cation of 30 per cent. In summary, this patient in whom definitive operation for adenomatous hyperplasia of the endometrium was delayed was found to have an associated estrogen-producing ovarian neoplasm. The clinical discovery of the patient’s ovarian tumor occurred two years after the diagnosis of adenomatous hyperplasia of the endometrinm was made. In addition to the possible developnlent of endometrial malignancy, the .occurrence of an estrogen-producing tumor of the ovary, though rare, should be considered when planning treatment for the patient with the diagnosis of adenomatous hyperplasia of the endometrium.
Adenocarcinoma of endometriosis of the ovary: A case report EDWARD Greensboro,
B. MABRY, North
M.D.
Carolina
THERE ARE THREE ASPECTS of this report that seem noteworthy: (1) The occurrence of adenocarcinoma in ovarian endometrioPresented by invitation at the Thirty-third Annual ing of the South Atlantic Association of Obstetricians ~~yneco~ogists, Atlanta, Georgia, February 7-10, 1971.
Meetand
presentation
783
sis is rare; (2) the pathogenesis of adenocarrinoma of the ovary may not always be the same; (3) the treatment may vary depending upon the pathogenesis. Sampson,l in 1925, described the eticllogy, pathogenesis, and criteria for diagnosis of this lesion. During the last fifteen to twenty years, more attention has been given to this problfmz-s The efficacy of treating uterine adenocarcinoma with high doses of progesterone has been reported by several investigators. 6-s This discovery led to further consideration of the use of high doses of progesterone in the treatment of carcinoma arising from ovarian endometriosis. A 25-year-old Caucasian married woman, para 0, complained of infertility. She was first examined on August 26, 1969. She had been married for five years and had used no contraception for the two immediately preceding years. Prior to the last two years, she had been taking a sequential contraceptive agent. Her periods had always been regular and normal. Menarche occurred at age 11; she had bled every twenty-eight to thirty days, and the amount of bleeding was constant and predictable, the flow lasting about five days. She had never complained of excessive dysmenorrhea. Her general health had been good. A tonsillectomy had been performed when she was a child. Prior to her marriage, she had a ruptured ovarian cyst, but operation was not performed. She was told in 1967 by her family physician that she had another cyst on her ovary. Examination revealed a well-developed, wellnourished Caucasian woman. The general physical examination and laboratory studies were normal. On pelvic examination, the external genitals, hair, skin, Bartholin’s and Skene’s glands, clitoris, and urethra were normal. The vagina was clean. The cervix was clean, nulliparous, and in mid-pcasition. The uterus was of normal size and slightly anteflexed. The uterine cavity was sounded 2% inches and was anterior. No adnexal masses were palpable. There was no tenderness and no nodularity palpable in the pelvis. Rectovaginal examination confirmed these findings. During the next three to four months, the infertility work-up revealed no abnormalities. On December 12, 1969, a pelvic examination revealed a 4 to 5 cm. right ovarian cyst. The tumor persisted until April, 1970. Operation was performed on April 15, 1970. Extensive endometriosis involved both ovaries and the cul-de-sac. The endometriosis in both ovaries was excised, leaving the uninvolved portion of each ovary. The essential gross pathologic findings were a 2.5 cm. cyst of the right ovary containing brown fluid with a 1 by 1 cm. papillary formation on the lining surface, a 1 cm. firm area, and a 1.5 cm. corpus Iuteum. Microscopically, the cyst was lined by endometrial glands and stroma which in places formed papillary projections into the lumen of the cyst. There was a focus of invasion of ,>varian
784
Patient
presentation
Amer.
stroma. The epithelium showed atypia, and there were many areas of squamous metaplasia. There was a 1 cm. area in which the glands were closely placed with little or no intervening stroma. The cells had hyperchromatic nuclei which varied in size. Mitoses were present. Endometriosis was present in both ovaries. Diagnosis was endometrioid carcinoma (adenoacanthoma pattern) of the right ovary and endometriosis of the right and left ovaries. On May 14, 1970, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. The omentum was grossly normal and was not removed. There was residual endometriosis but no malignancy in any of the tissue. Postoperatively, 500 mg. of medroxyprogesterone acetate* was administered intramuscularly at weekly intervals for the next twelve weeks and then intramuscularly once each month. This medication has been tolerated well, and she has reported no untoward effects. She has remained well, and no tumor is demonstrable. The incidence of this disease is difficult to ascertain. Often, at the time of operation, the extent of carcinoma is so great that no definite link with pre-existing endometriosis can be established. It is possible that, as Dockertys suggests, the incidence of carcinoma arising from endometriosis of the ovary may be much higher than it appears. Sampson1 earlier mentioned this possibility also, and he listed strict criteria necessary to establish that an adenocarcinoma of the ovary arose from endometriosis in that ovary. These criteria were met in this patient. Sampson1 and later Long and Taylor4 as well as others speculated that endometrial tumors might arise directly from ovarian serosa. It seemed reasonable that the embryologic potential of coelomic epithelium could be retained and differentiate into various tissues, including the uterine epithelium. Thus, endometrial tumors of the ovary could arise with no demonstrable evidence of endometriosis. The third facet of the problem is related to treatment. If it is established that this condition arose as a result of ovarian serosal change with differentiation directly into ovarian adenocarcinoma, it would seem reasonable that the usual treatment of adenocarcinoma of the ovary would be appropriate. This would include a surgical procedure and irradiation or chemotherapy, with the use of one of the alkylating agents such as chlorambucil. However, if we determined conclusively that the carcinoma arose primarily from endometriosis in the ovary, then it would seem that the most
‘Depo-Provera, Michigan.
The
Upjohn
Company,
K&unazoo,
July 1.5, IWI J. Obstct. Gynr<
efficacious treatment would be that commonly used to treat adenocarcinoma of the endometrium. In this patient, we believed the evidence supported the latter pathogenesis and treated the patient accordingly. REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Sampson, J. A.: Arch. Surg. 10: 1, 1925. Dockerty, M. B.: AMER. J. OBSTET. GYNEC. 83: 175, 1962. Scully, R. E., Richardson, G. S., and Barlow, J. F.: Clin. Obstet. Gynec. 9: 384, 1966. Long, M. E., and Taylor, H. C.: AMER. J. OBSTET. GYNEC. 90: 936, 1964. Anderson, D. C.: AMER. J. OBSTET. GYNEC. 92: 87, 1965. Kelley, R. M., and Baker, W. H.: Progr. Gynec. 4: 436, 1963. Kistner, R. W.: Cancer 12: 1106, 1959. Varga, A., and Henricksen, E.: Obstet. Gynec. 18: 658, 1961.
Pregnancy in paraplegic Two case reports WILLIAM Richmond,
M. OPPENHIMER, Virginia
patients: M.D.
ACCIDENTS and other diverse forms of trauma have led to an increasing number of paraplegic and quadraplegic women. Relatively little has appeared in the obstetric literature concerning this rather uncommon clinical entity.
AUTOMOBILE
The pregnant spinal cord-injury patient presents certain unusual and difficult problems, such as autonomic dysreflexia, which should be recognized. The following case reports and discussion point up some of these problems and provide a framework for the rational treatment of these unfortunate patients. Case 1. Mrs. M. W. sustained a motor and sensory paraplegia at the levels of the eleventh and twelfth thoracic vertebrae as a result of a fracture dislocation at age 14 while she was horseback riding. Menarche had occurred at age 11, and menses resumed 7 months after the accident at 29 day intervals. Postinjury bladder training was successful. In 1966, at age 35, she conceived after 7 years of marriage and had an uneventful prenatal course.
Presented ing of the Gynecologists,
by invitation at the Thirty-third Annual South Atlantic Association of Obstetricians Atlanta, Georgia, February 7-10, 1971.
Meetand