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Bilateral Brenner tumors of the ovaries
BILATERAL SIDNEY (F,rom
the
J.
PECK,
Departments
BRENNER
M.D.,” of
AND
Obstetrics
TUMORS GERALD
LEARY,
andGynecology
OF THE
M.D., and
OVARIES
PORTLAND,
Pathology,
MAINE Mercy
Hospital)
RTHMRNI described what was probably the first reported case of a Brenner tumor of the ovary. Eight years later, in 1907, Brennerx described three such cases, at which ” because he believed the source to be time he termed the tumor “oophoroma foliiculare, In 1932 Robert Meyers more clearly defined and classified these ovarian tumors. the follicle. He believed that they arose from Walthard’s inclusions, and were not granulosa-cell On the other hand, Sehillerk pointed out that in some instances these tumors may growths. arise from Wolffian epoophoron tubules which are included in the ovarian hilum and which may form epithelium like that normally found in the urinary tract. Johnson and Dockerty” mention a third hypothesis pertaining to the origin of these tumors, namely, that they may be of teratomatous origin based on the fact that about one-third of Brenner tumors occur in the walls of mutinous cysts of the ovary. A mutinous cyst so frequently is part of a dermoid cyst that many investigators consider it to be a teratoma with overgrowth of mucous glands to the exclusion of other elements. However, Meyer’s theory is still the one most widely accepted. The Brenner tumor is slow growing and considered to be a benign lesion. Over 50 per cent oezur beyond the age of 50 years. It comprises 2 per cent of all solid ovarian tumors, which in turn comprise only 20 per cent of all ovarian tumors. Seventy per cent of the Brenner tumors are solid, while thirty per cent are present in the wall of a cyst, It is usually unilateral, but it may be bilateral. usually a pseudomucinous cystadenoma. In 1942 Fox6 reviewed the literature and found that among 170 cases of Brenner tumor there were only 13 cases (7.6 per cent) in which the growth was bilateral. Johnson and Doekertyb reported the fourteenth case of bilateral Brenner tumor in 1945. The Brenner tumor produces no hormonal disturbances of the endometrium and no characteristm symptoms so that it is usually found incidentally at operation or autopsy. The size of the tumor varies between a few millimeters to several centimeters, the largest recorded bei.ng 15 pounds, as reported by Neiman.7 Grossly, the solid form has the appearance of a fibroma, the cut surface however, presenting a yellowish tint. Hemorrhage and necrosis are rare findings. Microscopically, the chief danger is in mistaking the Brenner tumor for a primary or metastatic epithelioma. However, the predominantly fibrous nature of the growth, the striking uniformity of the cells and the complete absence of mitosis help to differentiate it from a malignancy. Two features appear to be necessary for a diagnosis, namely, the characteristic nests of epithelial cells, which resemble squamous cells, although they do not possess intercellular bridges or keratin and a fibromatous connective tissue stroma surrounding the epithelial nests. The patient was a 35-year-old white woman, para ii, gravida ii, who was first seen on Jan. 25, 1952, complaining of a dragging sensation in the lower pelvis for several years, low backache for several weeks, and severe urinary stress incontinence. There were no menstrual alterations. She had had an appendectomy at the age of 16 and a Sturmdorf cervical amputation for chronic cervicitis 13 years ago. Family history was essentially noncontributory. Bhysica.1 findings were essentially normal except for the following: The thyroid isthmus was palpable and smooth. She exhibited fine tremors of the fingers of the hands.
0
*Present
address,
265
Middle
Neck
Road,
Great 1179
Neck,
N.
Y.
PECK
AND
LEARY
Am. J. Obst. & Gynec. November.
1952
Basal metabolic rate was plus 13. Examination of the heart revealed a soft systolic bldw at, the apex. On pelvic examination the external genitals were negative. She presented a urethrocele, a third-degree cystocele, a second-degree rectocele, an enterocele, and a second-degree uterine descensus. The uterine fundus was anterior, normal in size, mobile, and smooth. The left ovary was palpable and slightly irregular, but not enlarged. The right ovary was palpated in the posterior cul-de-sac, was enlarged to about 4 by 5 em., was hard, irregular, tender, and freely mobile. On Jan. 29, 1952, she underwent a vaginal hysterectomy, an anterior and posterior colporrhaphy, a urethral plication, and repair of the enterocele. At operation both ovaries and tubes were visualized. The right ovary was enlarged to about 4 by 5 cm., and was A right salpingo-oophorectomy was performed. On cut section the hard and irregular. Immediate frozen section revealed a tumor mass was solid and had a yellowish tint. Brenner tumor of the ovary. The left ovary was not enlarged but was irregular and presented a hard mass in the upper pole which measured 2 cm. in size. This mass was enuOn microscopic examination this cleated in order to conserve the remaining ovarian tissue. mass was also a Brenner tumor of the ovary. The patient was discharged from the hospital on Feb. 7, 1952, after an uneventful postoperative course.
SWmmaI.y An
A total additional
of fourteen case has
cases of bilateral been presented.
Brenner
tumor
of the
ovary
have
been
reported.
References 1. 2. 3. 4. ;.
Orthman, E. Brenner, F.: Meyer, R.: Sohiller, W.: $o&ns;,AJ. 7: NeiLa;, l?,
G.: Monatschr. f. Geburtsh. u. GynSik. 9: 771,1899. Frankfurt. Ztschr. f. Path. 1: 150, 1907. Arch. f. GynSik. 148: 541, 1932. Arch. f. Gyniik. 157: 65, 1934. Proc. Staff Meet., Mayo R., and Dockerty, M. B.: Am. J. Path. 18: 223, 1942. H.: Arch. Path. 21: 55, 1936.
Clin.
20:
120,
1945.
the
J.
PECK,
Departments
BRENNER
M.D.,” of
AND
Obstetrics
TUMORS GERALD
LEARY,
andGynecology
OF THE
M.D., and
OVARIES
PORTLAND,
Pathology,
MAINE Mercy
Hospital)
RTHMRNI described what was probably the first reported case of a Brenner tumor of the ovary. Eight years later, in 1907, Brennerx described three such cases, at which ” because he believed the source to be time he termed the tumor “oophoroma foliiculare, In 1932 Robert Meyers more clearly defined and classified these ovarian tumors. the follicle. He believed that they arose from Walthard’s inclusions, and were not granulosa-cell On the other hand, Sehillerk pointed out that in some instances these tumors may growths. arise from Wolffian epoophoron tubules which are included in the ovarian hilum and which may form epithelium like that normally found in the urinary tract. Johnson and Dockerty” mention a third hypothesis pertaining to the origin of these tumors, namely, that they may be of teratomatous origin based on the fact that about one-third of Brenner tumors occur in the walls of mutinous cysts of the ovary. A mutinous cyst so frequently is part of a dermoid cyst that many investigators consider it to be a teratoma with overgrowth of mucous glands to the exclusion of other elements. However, Meyer’s theory is still the one most widely accepted. The Brenner tumor is slow growing and considered to be a benign lesion. Over 50 per cent oezur beyond the age of 50 years. It comprises 2 per cent of all solid ovarian tumors, which in turn comprise only 20 per cent of all ovarian tumors. Seventy per cent of the Brenner tumors are solid, while thirty per cent are present in the wall of a cyst, It is usually unilateral, but it may be bilateral. usually a pseudomucinous cystadenoma. In 1942 Fox6 reviewed the literature and found that among 170 cases of Brenner tumor there were only 13 cases (7.6 per cent) in which the growth was bilateral. Johnson and Doekertyb reported the fourteenth case of bilateral Brenner tumor in 1945. The Brenner tumor produces no hormonal disturbances of the endometrium and no characteristm symptoms so that it is usually found incidentally at operation or autopsy. The size of the tumor varies between a few millimeters to several centimeters, the largest recorded bei.ng 15 pounds, as reported by Neiman.7 Grossly, the solid form has the appearance of a fibroma, the cut surface however, presenting a yellowish tint. Hemorrhage and necrosis are rare findings. Microscopically, the chief danger is in mistaking the Brenner tumor for a primary or metastatic epithelioma. However, the predominantly fibrous nature of the growth, the striking uniformity of the cells and the complete absence of mitosis help to differentiate it from a malignancy. Two features appear to be necessary for a diagnosis, namely, the characteristic nests of epithelial cells, which resemble squamous cells, although they do not possess intercellular bridges or keratin and a fibromatous connective tissue stroma surrounding the epithelial nests. The patient was a 35-year-old white woman, para ii, gravida ii, who was first seen on Jan. 25, 1952, complaining of a dragging sensation in the lower pelvis for several years, low backache for several weeks, and severe urinary stress incontinence. There were no menstrual alterations. She had had an appendectomy at the age of 16 and a Sturmdorf cervical amputation for chronic cervicitis 13 years ago. Family history was essentially noncontributory. Bhysica.1 findings were essentially normal except for the following: The thyroid isthmus was palpable and smooth. She exhibited fine tremors of the fingers of the hands.
0
*Present
address,
265
Middle
Neck
Road,
Great 1179
Neck,
N.
Y.
PECK
AND
LEARY
Am. J. Obst. & Gynec. November.
1952
Basal metabolic rate was plus 13. Examination of the heart revealed a soft systolic bldw at, the apex. On pelvic examination the external genitals were negative. She presented a urethrocele, a third-degree cystocele, a second-degree rectocele, an enterocele, and a second-degree uterine descensus. The uterine fundus was anterior, normal in size, mobile, and smooth. The left ovary was palpable and slightly irregular, but not enlarged. The right ovary was palpated in the posterior cul-de-sac, was enlarged to about 4 by 5 em., was hard, irregular, tender, and freely mobile. On Jan. 29, 1952, she underwent a vaginal hysterectomy, an anterior and posterior colporrhaphy, a urethral plication, and repair of the enterocele. At operation both ovaries and tubes were visualized. The right ovary was enlarged to about 4 by 5 cm., and was A right salpingo-oophorectomy was performed. On cut section the hard and irregular. Immediate frozen section revealed a tumor mass was solid and had a yellowish tint. Brenner tumor of the ovary. The left ovary was not enlarged but was irregular and presented a hard mass in the upper pole which measured 2 cm. in size. This mass was enuOn microscopic examination this cleated in order to conserve the remaining ovarian tissue. mass was also a Brenner tumor of the ovary. The patient was discharged from the hospital on Feb. 7, 1952, after an uneventful postoperative course.
SWmmaI.y An
A total additional
of fourteen case has
cases of bilateral been presented.
Brenner
tumor
of the
ovary
have
been
reported.
References 1. 2. 3. 4. ;.
Orthman, E. Brenner, F.: Meyer, R.: Sohiller, W.: $o&ns;,AJ. 7: NeiLa;, l?,
G.: Monatschr. f. Geburtsh. u. GynSik. 9: 771,1899. Frankfurt. Ztschr. f. Path. 1: 150, 1907. Arch. f. GynSik. 148: 541, 1932. Arch. f. Gyniik. 157: 65, 1934. Proc. Staff Meet., Mayo R., and Dockerty, M. B.: Am. J. Path. 18: 223, 1942. H.: Arch. Path. 21: 55, 1936.
Clin.
20:
120,
1945.