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Bladder Tumor, Arising from an Ovarian Dermoid Cyst: Case Report
BLADDER TUMOR, ARISING FROM AN OVARIAN DERMOID CYST CASE REPORT
JOHN MACMILLAN TOWNSEND
Tumor of the bladder or perforation of the bladder arising from an ovarian dermoid cyst is a relatively rare occurrence, judging from the small number of cases reported. Such a condition was first reported by Wallace in 1700. Numerous other cases have been recorded, many of which the authenticity can not be proven. Germaine (1909) reported 25 cases and added one of his own. Clado (1895) collected 32 cases of paravesical dermoid cysts, in 18 of which the only symptoms were micturition of hair. Quinby (1919) again called our attention to this condition and reported 3 cases. Since that time several isolated cases have been reported. Until the advent of the cystoscope and roentgenogram the diagnosis depended upon such facts as could be obtained from the history and physical examination, such as pilimiction (passage of hair during urination), pyuria, hematuria, passage of gas per urethra or any of the component structures of a dermoid cyst. Several cases have been reported where the patient passed one or more teeth while voiding. A pelvic tumor mass was usually present to support these other findings in making a diagnosis. Quinby was one of the first to bring to our attention the urological aspects of dermoid cysts in and about the bladder. Ewell, and later Shih and Char have clearly and concisely brought out that there is nothing suggestive about the history except the passage of hair and other detritus common to dermoids which constitute a major symptom. In our case the major symptom was absent and the true condition became evident only after cystoscopy and biopsy. Two pathological conditions were present in our case, which probably accounted for the perforation of the bladder by the dermoid cyst and the unusual tumor growth within the bladder: (1) was infection of the dermoid, which is relatively common, causing it to become adherent to the bladder wall and possibly resulting in necrosis; (2) the direction or axis in which the germinal center or plug of the dermoid was pointed. 101
102
JOHN MACMILLAN TOWNSEND
Upon the activity of the germinal center depends the size and rapidity of growth of the dermoid cyst. The rupture of the bladder probably followed the infection of the cyst to be later followed by an abundant growth of dermoid tissue to the bladder as the germinal center became activated. Treatment by curettage and lavaging of the cyst cavity has resulted in some temporary alleviation of symptoms, but has not proven curative. This treatment, in our opinion, has very little if any scientific rationale and is not to be recommended. Complete extirpation of the dermoid cyst in any growth projecting into the bladder has proven most satisfactory. This method of treatment has proven true in those cases previously reported and also here reported. Case report. A female aged 21, entered the hospital on April 19, 1938, complaining chiefly of burning and frequency on urination and pain in the left lower quadrant. She had had a severe cystitis for 18 months, following her first pregnancy. Cystoscopy disclosed cystitis as the result of an acute right pyelitis. This condition was relieved by urinary antiseptics and pelvic lavage. Within a short time she began complaining of a dull aching pain in the left lower quadrant and was thought to have a pelvic abscess probably of tubal origin. No operative work was carried out at this time. Five months later the pain in the left lower quadrant became much more severe and the frequency and dysuria increased. Four months previous to the date of her admission she first noticed gross hematuria. No clots were present and the urine was bright red in color. At this time she was able to urinate only a few drops at a time, the frequency having become so severe that it amounted to almost an incontinence. Shortly afterwards she passed a few small blood clots and a large amount of gas per urethra. There was no history of passage of calculi or other detritus common to dermoid cysts. The urine had a very foul odor. Laboratory data: Urinalysis showed400 pus cells per high powered field, 200 red blood cells, alkaline reaction, many bacteria. Right ureteral specimen, no pus; left ureteral specimen, 3 pus cells per low powered field. Blood count: Hemoglobin 70 per cent; red blood cells 3,750,000; white blood cells 6,600; polymorphonuclears 64 per cent; Lymphocytes 36 per cent; non-protein nitrogen 22.8 rugs. per 100 cc. blood. Wassermann and Kahn tests negative. The patient was poorly nourished, and did not appear to be acutely· ill. Examination was essentially negative except that a tender mass apparently 10 cm. in diameter was felt in the left lower quadrant. The origin of this mass could not be determined, although the cervix of the uterus appeared to be freely movable and soft in consistency. A No. 24 Brown Buerger cystoscope showed a markedly contracted bladder
103
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with a capacity of about 90 cc. There was a tumor mass arising posterior and lateral of the left ureteral orifice from which appeared to be growing a large number of black curly hairs. Both ureteral orifices could be seen and were catheterized with ease for 25 cm. An air cystogram showed a marked filling defect apparently occupying at least one-half of the bladder surface. On April 21, 1938 under sodium pentothal anesthesia a midline incision was made down to the peritoneum. The peritoneum was found to be extremely thick and indurated over the bladder and lower portion of the peritoneal cavity. We had planned to open the bladder and excise this growth,
FIG. 1
FIG. 2
FIG. 1. Air cystogram showing filling defect caused by bladder tumor arising from dermoid cyst. FIG. 2. Postoperative air cystogram showing practically a normal bladder.
but because of the pathological finding present it was thought best to open the peritoneum and explore the pelvic mass. Examination revealed that the right half of the bladder wall appeared to be normal. The uterus was of normal size and the mass in the left lower quadrant was very hard, nodular and almost completely covered by loops of small intestine and omentum. It was thought best simply to excise one of these nodules for biopsy purposes and the abdomen was closed without drainage. The report on the biopsy specimen was simply chronic inflammatory reaction of a lymph node. On cystoscopy on April 27, 1938 under sodium pentothal anesthesia several large pieces of the tumor mass were removed by excision with the Stern-
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McCarthy resectoscope. These pieces were relatively avascular and contained many black hairs growing from their surface. Microscopic examinatfon disclosed numerous sebaceous glands, hair follicles and other skin structures and a diagnosis of some type of tumor arising from a dermoid cyst was made. It was thought possible to remove this mass in the pelvis, which was evidently a dermoid cyst which had ruptured through into the bladder. On May 11, 1938 under sodium pentothal anesthesia a midline incision was made and the pelvic mass explored. In attempting to free the pelvic mass, the bladder was ruptured at the point of penetration of the growth. The bladder was then opened widely and the mass which had been seen in the bladder was found to be largely pedunculated and the bladder wall for about 1 cm. around the point of penetration was very friable and necrotic. A ureteral catheter, which had been previously placed up the left ureter, was found to be approximately 2 cm. from the point of perforation by this tumor mass. The tumor mass was removed with practically no bleeding. The necrotic area around the point of penetration was excised. The tumor mass in the pelvis was then attacked and we were able to free it from the dense adhesions between it and the omentum, and it was found that the mass consisted of an ovary approximately 6 cm. by 10 cm. In a process of freeing these adhesions, small multiplr abscesses were encountered throughout this portion of the omentum. The bladder was then closed by 2 continuous chromic 2 sutures and a No. 28 Pezzar catheter was placed in the bladder for drainage. Two rubber tissure drains were used, one being placed where the opening had been in the left side of the bladder and the other one was placed in the region of the indurated omentum which contained several loops of small intestines. The usual closure was then made. The patient continued to run a moderately elevated temperature for about one week and there was a rather profuse purulent drainage from the pelvis. On the 21st day all drainage had ceased, the bladder urine was clear and the suprapubic catheter was removed. One month later the patient was voiding grossly clear urine with no frequency or dysuria. All induration and pain in the left lower quadrant had completely disappeared and the suprapubic sinus was entirely healed. The bladder capacity was 180 cc. and an air cystogram showed a normal bladder. Pathological report (Dr. .G. S. Graham and Dr. L. C. Posey): The specimen consists of an ovary 7 by 6 by 3 cm. It is enlarged, firm, and surface is scarred by old fibrous deposits. Along one margin is a defect 1.7 cm. in diameter, it is a sinus tract which continues into the middle of the ovarian mass and dilates into a cystic cavity, 3.5 by 2.5 cm. The cavity is surrounded by dense grey scar tissue and contains a dull grey folded membranous lining to which are attached large numbers of kinky black hairs. The outlying tissue surrounding the cyst shows ovarian cortex in which there are few large follicles 2 to 3 mm. in diameter.
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105
Attached at the side opposite the defect is the oviduct measuring 3.5 by .9 cm. Its surface is roughened by fine fibrous deposits and its wall is thick and dense. The mes-ovarium is markedly thickened and rigid. Accompaning the specimen is a papillary mass covered by wrinkled negro skin which at the extreme apex contains no pigment. This mass is 4 by 2.5 cm. and its pedicle is .9 cm. The pedicle fits readily into the sinus defect, described in the ovary, and apparently represents a progressing bud of the dermoid. On section a small core of dense bone is present in the middle of this skin covered mass. A few hairs arise from the surface.
FrG. 3. Pathological specimen of dermoid cyst and germinal center which invaded bladder, also a mass of hair ,,hich escaped from dermoid during removal.
Received separately are two masses of kinky black hair mixed with a cheesy dull yellowish grey semi-solid material. Section of ovary including the wall of the central cyst shows a diffuse fibrosis of ovarian stroma and a diffuse infiltration by lymphocytes which are occasionally collected into small groups. Scattered through the substance are large lymphatic or venous spaces which are at present empty. In the looser tissue about these spaces there are frequent giant cells containing fat vacuoles and there are large numbers of monocytes containing finely granular yellowish pigment. These often occur in small groups, however they frequently occur singly. An occasional ovum can be seen in a primordial follicle. They usually show a marked degeneration, liquefaction and solution. Toward the central cyst, fibrous tissue becomes denser and the tissues are infiltrated by numerous
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JOHN MACMILLAN TOWNSEND
plasma cells.. Fibrous tissue eventually forms a thick capsule about the margin of the cyst. The cyst is lined by a granulation tissue containing great numbers of leucocytes consisting of about equal numbers of neutrophils and plasma cells. An occasional pigment laden cell and foreign body giant cell may be seen. This granulation tissue is lightly vascularized and the capillaries are engorged with lymphocytes. Young fibroblasts are frequent. The cyst lumen contains inflammatory exudate. Another section of ovary shows corpora albicantia and occasional follicle cyst. Giant cells of foreign body type are frequent. A narrow segment of the central cyst is included. Section of the papillary skin mass shows a pigmented stratified squamous epithelium with an irregular papillary surface covered by a thick keratin layer and containing an occasional sebaceous gland. At one margin the epithelium gives way to an ulcer the floor of which is formed by fresh fibrin and leucocytes, predominantly neutrophils. Beneath the exudate is a mass of granulation tissue which is also infiltrated by neutrophils. In the deeper tissue there is focal infiltration of lymphocytes and occasional neutrophils. On one side is a portion of a cavity lined by a stratified columnar epithelium of respiratory type. A third block from the base of the protruding skin covered nodule shows another remnant of the cavity lined by respiratory epithelium. Immediately below this toward the more basal portion is a larger mass of well formed membranous bone. Toward one side is a small oval fragment of cartilage, the mass is covered by pigment skin as described above and the sub-cutaneous layer containing greater numbers of sebaceous glands. A few cystic cavities are lined by respiratory epithelium. Some show infiltration of their walls by monocytes. In one area a small area is lined by pigment producing tissue. The pigment suggests melinin and occurs in dark brownish-black granules. Microscopic diagnosis: Peri-ovarian adhesions, Ruptured ovarian dermoid cyst with the extrusion of the germinal nucleus into the bladder. Comment: The tumor contains pigmented epithelium with hairs, sebaceous glands and partial ulceration of the surface. The deeper structure contains cysts lined by respiratory epithelium. Another cyst is lined by pigment bearing tissue suggesting choroid retina. In the basal portion a core of bone and a fragment of cartilage is present. Chronic inflammatory changes through the entire ovary are due to absorption of the material from the dermoid cyst. We were aware prior to the first laparotomy that a tumor mass existed in the left lower pelvis, but we were undecided whether this was a benign or malignant type of growth. It was felt that an exploration laparotomy was justified, on the grounds that if it was benign that definite operative relief could be undertaken at that time. Upon entering the abdomen, the mass was so hard and nodular that a tentative diagnosis of a malig-
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107
nant teratoma was made and a nodule was secured for biopsy. The nodule on microscopic section later proving to be chronic inflammatory reaction. After this report was obtained, it was felt that a section of the bladder tumor might be obtained safely. This procedure was done and the diagnosis was definitely established. The second laporatomy was then done completely removing all bladder involvement, as well as the original focus, namely the dermoid cyst. Infection arising from multiple abscesses in the omentum adherent to the cyst and urinary leakage, appeared to be the greatest post-operative hazard. The indurated and infected omentum was not resected, because it contained numerous loops of ileum and also because we felt it probably had developed a high degree of local immunity to the infection. The patient was therefore placed in a semi-Fowler's position for several days post-operatively, and the local peritoneal infection could be considered minimal. The end result from this procedure, we consider quite satisfactory. SUMMARY
A case of benign bladder tumor arising from an ovarian dermoid cyst is presented. The rarity of the condition is shown as evidenced from a review of the literature. Treatment consisted of complete removal of the dermoid cyst and bladder tumor arising from it. Diagnosis usually has to be made by cystoscopy, x-ray, and if possible biopsy.
2501 Sixteenth Ave., Birmingham, Ala. REFERENCES DrPAL1'1:A AND STARK: Surg., Gynec. and Obst., 48: 419, 1929. DONOHUE, P. F.: J. Ural., 40: 27, 1938. EWELL, G. H.: Am. J. Surg., 19: 502, 1933. GERMAINE, J. J.: Thesis, Lyon, 1909. QUINBY, w. C.: J. A. M. A.: 73: 1045, 1919. SHIH AKD CHAR: J. Ural., 38: 165, 1937. THOMAS AND EXLEY: J. Ural., 23: 587, 1930. WALLACE, J.: Philosophical Trans., Royal Society of London, 22: 688, 1700. WALLACE AKD WONG: Chinese M. J., 53: 467, 1938.
JOHN MACMILLAN TOWNSEND
Tumor of the bladder or perforation of the bladder arising from an ovarian dermoid cyst is a relatively rare occurrence, judging from the small number of cases reported. Such a condition was first reported by Wallace in 1700. Numerous other cases have been recorded, many of which the authenticity can not be proven. Germaine (1909) reported 25 cases and added one of his own. Clado (1895) collected 32 cases of paravesical dermoid cysts, in 18 of which the only symptoms were micturition of hair. Quinby (1919) again called our attention to this condition and reported 3 cases. Since that time several isolated cases have been reported. Until the advent of the cystoscope and roentgenogram the diagnosis depended upon such facts as could be obtained from the history and physical examination, such as pilimiction (passage of hair during urination), pyuria, hematuria, passage of gas per urethra or any of the component structures of a dermoid cyst. Several cases have been reported where the patient passed one or more teeth while voiding. A pelvic tumor mass was usually present to support these other findings in making a diagnosis. Quinby was one of the first to bring to our attention the urological aspects of dermoid cysts in and about the bladder. Ewell, and later Shih and Char have clearly and concisely brought out that there is nothing suggestive about the history except the passage of hair and other detritus common to dermoids which constitute a major symptom. In our case the major symptom was absent and the true condition became evident only after cystoscopy and biopsy. Two pathological conditions were present in our case, which probably accounted for the perforation of the bladder by the dermoid cyst and the unusual tumor growth within the bladder: (1) was infection of the dermoid, which is relatively common, causing it to become adherent to the bladder wall and possibly resulting in necrosis; (2) the direction or axis in which the germinal center or plug of the dermoid was pointed. 101
102
JOHN MACMILLAN TOWNSEND
Upon the activity of the germinal center depends the size and rapidity of growth of the dermoid cyst. The rupture of the bladder probably followed the infection of the cyst to be later followed by an abundant growth of dermoid tissue to the bladder as the germinal center became activated. Treatment by curettage and lavaging of the cyst cavity has resulted in some temporary alleviation of symptoms, but has not proven curative. This treatment, in our opinion, has very little if any scientific rationale and is not to be recommended. Complete extirpation of the dermoid cyst in any growth projecting into the bladder has proven most satisfactory. This method of treatment has proven true in those cases previously reported and also here reported. Case report. A female aged 21, entered the hospital on April 19, 1938, complaining chiefly of burning and frequency on urination and pain in the left lower quadrant. She had had a severe cystitis for 18 months, following her first pregnancy. Cystoscopy disclosed cystitis as the result of an acute right pyelitis. This condition was relieved by urinary antiseptics and pelvic lavage. Within a short time she began complaining of a dull aching pain in the left lower quadrant and was thought to have a pelvic abscess probably of tubal origin. No operative work was carried out at this time. Five months later the pain in the left lower quadrant became much more severe and the frequency and dysuria increased. Four months previous to the date of her admission she first noticed gross hematuria. No clots were present and the urine was bright red in color. At this time she was able to urinate only a few drops at a time, the frequency having become so severe that it amounted to almost an incontinence. Shortly afterwards she passed a few small blood clots and a large amount of gas per urethra. There was no history of passage of calculi or other detritus common to dermoid cysts. The urine had a very foul odor. Laboratory data: Urinalysis showed400 pus cells per high powered field, 200 red blood cells, alkaline reaction, many bacteria. Right ureteral specimen, no pus; left ureteral specimen, 3 pus cells per low powered field. Blood count: Hemoglobin 70 per cent; red blood cells 3,750,000; white blood cells 6,600; polymorphonuclears 64 per cent; Lymphocytes 36 per cent; non-protein nitrogen 22.8 rugs. per 100 cc. blood. Wassermann and Kahn tests negative. The patient was poorly nourished, and did not appear to be acutely· ill. Examination was essentially negative except that a tender mass apparently 10 cm. in diameter was felt in the left lower quadrant. The origin of this mass could not be determined, although the cervix of the uterus appeared to be freely movable and soft in consistency. A No. 24 Brown Buerger cystoscope showed a markedly contracted bladder
103
BLADDER TUMOR
with a capacity of about 90 cc. There was a tumor mass arising posterior and lateral of the left ureteral orifice from which appeared to be growing a large number of black curly hairs. Both ureteral orifices could be seen and were catheterized with ease for 25 cm. An air cystogram showed a marked filling defect apparently occupying at least one-half of the bladder surface. On April 21, 1938 under sodium pentothal anesthesia a midline incision was made down to the peritoneum. The peritoneum was found to be extremely thick and indurated over the bladder and lower portion of the peritoneal cavity. We had planned to open the bladder and excise this growth,
FIG. 1
FIG. 2
FIG. 1. Air cystogram showing filling defect caused by bladder tumor arising from dermoid cyst. FIG. 2. Postoperative air cystogram showing practically a normal bladder.
but because of the pathological finding present it was thought best to open the peritoneum and explore the pelvic mass. Examination revealed that the right half of the bladder wall appeared to be normal. The uterus was of normal size and the mass in the left lower quadrant was very hard, nodular and almost completely covered by loops of small intestine and omentum. It was thought best simply to excise one of these nodules for biopsy purposes and the abdomen was closed without drainage. The report on the biopsy specimen was simply chronic inflammatory reaction of a lymph node. On cystoscopy on April 27, 1938 under sodium pentothal anesthesia several large pieces of the tumor mass were removed by excision with the Stern-
104
JOHN MACMILLAN TOWNSEND
McCarthy resectoscope. These pieces were relatively avascular and contained many black hairs growing from their surface. Microscopic examinatfon disclosed numerous sebaceous glands, hair follicles and other skin structures and a diagnosis of some type of tumor arising from a dermoid cyst was made. It was thought possible to remove this mass in the pelvis, which was evidently a dermoid cyst which had ruptured through into the bladder. On May 11, 1938 under sodium pentothal anesthesia a midline incision was made and the pelvic mass explored. In attempting to free the pelvic mass, the bladder was ruptured at the point of penetration of the growth. The bladder was then opened widely and the mass which had been seen in the bladder was found to be largely pedunculated and the bladder wall for about 1 cm. around the point of penetration was very friable and necrotic. A ureteral catheter, which had been previously placed up the left ureter, was found to be approximately 2 cm. from the point of perforation by this tumor mass. The tumor mass was removed with practically no bleeding. The necrotic area around the point of penetration was excised. The tumor mass in the pelvis was then attacked and we were able to free it from the dense adhesions between it and the omentum, and it was found that the mass consisted of an ovary approximately 6 cm. by 10 cm. In a process of freeing these adhesions, small multiplr abscesses were encountered throughout this portion of the omentum. The bladder was then closed by 2 continuous chromic 2 sutures and a No. 28 Pezzar catheter was placed in the bladder for drainage. Two rubber tissure drains were used, one being placed where the opening had been in the left side of the bladder and the other one was placed in the region of the indurated omentum which contained several loops of small intestines. The usual closure was then made. The patient continued to run a moderately elevated temperature for about one week and there was a rather profuse purulent drainage from the pelvis. On the 21st day all drainage had ceased, the bladder urine was clear and the suprapubic catheter was removed. One month later the patient was voiding grossly clear urine with no frequency or dysuria. All induration and pain in the left lower quadrant had completely disappeared and the suprapubic sinus was entirely healed. The bladder capacity was 180 cc. and an air cystogram showed a normal bladder. Pathological report (Dr. .G. S. Graham and Dr. L. C. Posey): The specimen consists of an ovary 7 by 6 by 3 cm. It is enlarged, firm, and surface is scarred by old fibrous deposits. Along one margin is a defect 1.7 cm. in diameter, it is a sinus tract which continues into the middle of the ovarian mass and dilates into a cystic cavity, 3.5 by 2.5 cm. The cavity is surrounded by dense grey scar tissue and contains a dull grey folded membranous lining to which are attached large numbers of kinky black hairs. The outlying tissue surrounding the cyst shows ovarian cortex in which there are few large follicles 2 to 3 mm. in diameter.
BLADDER TUMOR
105
Attached at the side opposite the defect is the oviduct measuring 3.5 by .9 cm. Its surface is roughened by fine fibrous deposits and its wall is thick and dense. The mes-ovarium is markedly thickened and rigid. Accompaning the specimen is a papillary mass covered by wrinkled negro skin which at the extreme apex contains no pigment. This mass is 4 by 2.5 cm. and its pedicle is .9 cm. The pedicle fits readily into the sinus defect, described in the ovary, and apparently represents a progressing bud of the dermoid. On section a small core of dense bone is present in the middle of this skin covered mass. A few hairs arise from the surface.
FrG. 3. Pathological specimen of dermoid cyst and germinal center which invaded bladder, also a mass of hair ,,hich escaped from dermoid during removal.
Received separately are two masses of kinky black hair mixed with a cheesy dull yellowish grey semi-solid material. Section of ovary including the wall of the central cyst shows a diffuse fibrosis of ovarian stroma and a diffuse infiltration by lymphocytes which are occasionally collected into small groups. Scattered through the substance are large lymphatic or venous spaces which are at present empty. In the looser tissue about these spaces there are frequent giant cells containing fat vacuoles and there are large numbers of monocytes containing finely granular yellowish pigment. These often occur in small groups, however they frequently occur singly. An occasional ovum can be seen in a primordial follicle. They usually show a marked degeneration, liquefaction and solution. Toward the central cyst, fibrous tissue becomes denser and the tissues are infiltrated by numerous
106
JOHN MACMILLAN TOWNSEND
plasma cells.. Fibrous tissue eventually forms a thick capsule about the margin of the cyst. The cyst is lined by a granulation tissue containing great numbers of leucocytes consisting of about equal numbers of neutrophils and plasma cells. An occasional pigment laden cell and foreign body giant cell may be seen. This granulation tissue is lightly vascularized and the capillaries are engorged with lymphocytes. Young fibroblasts are frequent. The cyst lumen contains inflammatory exudate. Another section of ovary shows corpora albicantia and occasional follicle cyst. Giant cells of foreign body type are frequent. A narrow segment of the central cyst is included. Section of the papillary skin mass shows a pigmented stratified squamous epithelium with an irregular papillary surface covered by a thick keratin layer and containing an occasional sebaceous gland. At one margin the epithelium gives way to an ulcer the floor of which is formed by fresh fibrin and leucocytes, predominantly neutrophils. Beneath the exudate is a mass of granulation tissue which is also infiltrated by neutrophils. In the deeper tissue there is focal infiltration of lymphocytes and occasional neutrophils. On one side is a portion of a cavity lined by a stratified columnar epithelium of respiratory type. A third block from the base of the protruding skin covered nodule shows another remnant of the cavity lined by respiratory epithelium. Immediately below this toward the more basal portion is a larger mass of well formed membranous bone. Toward one side is a small oval fragment of cartilage, the mass is covered by pigment skin as described above and the sub-cutaneous layer containing greater numbers of sebaceous glands. A few cystic cavities are lined by respiratory epithelium. Some show infiltration of their walls by monocytes. In one area a small area is lined by pigment producing tissue. The pigment suggests melinin and occurs in dark brownish-black granules. Microscopic diagnosis: Peri-ovarian adhesions, Ruptured ovarian dermoid cyst with the extrusion of the germinal nucleus into the bladder. Comment: The tumor contains pigmented epithelium with hairs, sebaceous glands and partial ulceration of the surface. The deeper structure contains cysts lined by respiratory epithelium. Another cyst is lined by pigment bearing tissue suggesting choroid retina. In the basal portion a core of bone and a fragment of cartilage is present. Chronic inflammatory changes through the entire ovary are due to absorption of the material from the dermoid cyst. We were aware prior to the first laparotomy that a tumor mass existed in the left lower pelvis, but we were undecided whether this was a benign or malignant type of growth. It was felt that an exploration laparotomy was justified, on the grounds that if it was benign that definite operative relief could be undertaken at that time. Upon entering the abdomen, the mass was so hard and nodular that a tentative diagnosis of a malig-
BLADDER TUMOR
107
nant teratoma was made and a nodule was secured for biopsy. The nodule on microscopic section later proving to be chronic inflammatory reaction. After this report was obtained, it was felt that a section of the bladder tumor might be obtained safely. This procedure was done and the diagnosis was definitely established. The second laporatomy was then done completely removing all bladder involvement, as well as the original focus, namely the dermoid cyst. Infection arising from multiple abscesses in the omentum adherent to the cyst and urinary leakage, appeared to be the greatest post-operative hazard. The indurated and infected omentum was not resected, because it contained numerous loops of ileum and also because we felt it probably had developed a high degree of local immunity to the infection. The patient was therefore placed in a semi-Fowler's position for several days post-operatively, and the local peritoneal infection could be considered minimal. The end result from this procedure, we consider quite satisfactory. SUMMARY
A case of benign bladder tumor arising from an ovarian dermoid cyst is presented. The rarity of the condition is shown as evidenced from a review of the literature. Treatment consisted of complete removal of the dermoid cyst and bladder tumor arising from it. Diagnosis usually has to be made by cystoscopy, x-ray, and if possible biopsy.
2501 Sixteenth Ave., Birmingham, Ala. REFERENCES DrPAL1'1:A AND STARK: Surg., Gynec. and Obst., 48: 419, 1929. DONOHUE, P. F.: J. Ural., 40: 27, 1938. EWELL, G. H.: Am. J. Surg., 19: 502, 1933. GERMAINE, J. J.: Thesis, Lyon, 1909. QUINBY, w. C.: J. A. M. A.: 73: 1045, 1919. SHIH AKD CHAR: J. Ural., 38: 165, 1937. THOMAS AND EXLEY: J. Ural., 23: 587, 1930. WALLACE, J.: Philosophical Trans., Royal Society of London, 22: 688, 1700. WALLACE AKD WONG: Chinese M. J., 53: 467, 1938.