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Chronic inversion of the uterus with fibrosarcoma of the corpus
CHRONIC INVERSION FIBROSARCOMA WALTER
B
J.
REICH,
M.D.
OF THE UTERUS WITH OF THE CORPUS*
AND MITCHELL J. NECHTOW, M.D. CHICAGO, ILLINOIS
the origina neopIasm is not The gross appearance of the neopIasm too common, and because of the wiI1 vary; however, the usua1 site for unusual conditions present in this sarcomatous degeneration is in the center case, we considered it worthy of reporting. of fibromyomas. In the usua1 benign Sarcoma of the uterus is not common, it fibroid of the corpus the tissue is hard, is indeed much less frequent than carcinoma gIistening, and has the circuIar or whor1 of the corpus. Among various chnics and appearance when the tumor is cut; but in reports, about 3.5 to 4 per cent of uterine the sarcomatous changes, the tissue appears mahgnancies are sarcomatous. Novak and necrotic or “ cooked.” Anderson1 found that in a period of twentyMicroscopically, the sarcomatous changes five years they encountered onIy fifty-nine are very much the same as those of sarcoma cases of sarcoma of the uterus in compariin other parts of the body. The spindIe ceI1, son with I ,263 cases of various other uterine round ceI1, and various mixed-ceI1 types maIignancies. are the usua1 findings. However, Novak, It was C. Meyer and Rudolph Virchow Evans,2 and Kimbrough3 beIieve that the who in 1860 presented the first case of a degree of mitotic activity may reffect the uterine sarcoma before the obstetrica severity of the maIignancy and its cIinica1 society of BerIin. Since then, some eightyprognosis. five years, the subject of uterine sarcoma The incidence of sarcomatous degenerais stiI1 in need of additiona discussion and tion of fibromyomas is probabIy .5 to I per enlightenment. cent. Novak’s findings are about as above The majority of clinics agree in their whiIe KeIIy and CuIIen in rgog, found statistica figures that the reIationship about 1.2 per ‘cent; other cIinicians and between sarcoma and carcinoma are about pathoIogists range from .5 to 4 per cent. I to 30 or 40. The greatest age incidence is Kimbrough3 states that sarcoma originthat during or after the menopause. Its ating from fibromyomas bear a much metastases wiI1 find other organs via the brighter prognosis than the primary sarbIood stream, the Iymphatics, or by direct coma; and in his experience the favorabIe extension. The Iiver and Iungs are the ratio was 3 to I. commonest sites for metastases; however, The primary sarcomas originated in other organs, such as the brain, ovary, and about 75 per cent of women who were in kidney may aIso be invoIved. the postmenopausa1 age, and onIy IO per There is no specific prediIection for any cent in younger women. Because of this, race or coIor and no definite hereditary the incidence of cures are Iess during the factors. menopausa1 age as compared with the Pathology. WhiIe sarcoma of the uterus younger women. may arise from the muscle fiber of the An interesting and ingenious prognostic uterus, the connective tissue, or the endomethod of Evans2 and corroborated by metrium, the commonest source is the Kimbrough3 in reIation to the number of fibromyomas of the uterus. Our case deaIs mitotic figures per cubic mm. of tissue as to the severity of the maIignancy, can be with the Iatter type. ECAUSE
* From The Department of Gynecology, Cook County HospitaI and The Cook County Graduate School; from The Hektoen Institute for Medical Research, and from the Service of E. W. Fischmann, M.D., Chicago, Illinois. 710
VOL. LXXI,
No.
3
Reich,
Nechtow-Inversion
appIied to the sarcomas, both primary and secondary types. It may be stated that the mpre mitotic figures, the more maiignant is
FIG. I. Original photograph of inversion showing tumor mass with patient in lithotomy position.
FIG. 3. Microscopic
of Uterus
7I 1
not characteristic and the diagnosis is usuaIIy made during or after surgery or histoIogicaIIy. However, abnorma1 uterine
FIG. Z. Original
sections
the neopIasm ; the fewer or absence of mitotic figures Ieads to a Iess maIignant growth and consequentIy a better outIook. Symptomatology of uterine sarcoma is
A merican Journal of Surgery
photograph showing and tumor mass.
inversion
of fibrosarcoma.
b1ee d’mg during or after the menopause, especiaIIy when associated with fibroids, should make one suspicious of a probabIe sarcoma of the uterus. Also, an abnorma1
7 12 American Journal of Surgery Reich,
Nechtow-Inversion
Ieukorrhea in a patient with fibroids which may or may not be bIoody shouId give rise to a possibility of sarcoma uteri; and if the discharge becomes fouI due to decomposition of tissue or necrosis, it may aIs point to sarcoma. We observed a case in which abnormaIIy fast growing myomas proved to be sarcomatous. Our case of uterine fibrosarcoma was complicated by compIete chronic uterine inversion. Non-puerpera1 uterine inversions are usuaIIy caused by some sort of neopIasms of the fundus. These tumors by means of traction and in the presence of a reIaxed uterine waI1 wiI1 create an inversion. It is reasonabIe to assume that without the reIaxed uterine waI1 a spontaneous inversion is aImost impossibIe. Fibromyomas are the commonest tumors associated in a nonpuerpera1 inversion. CASE
REPORT
Mrs. J. S., No. 28928, age seventy-six, was admitted to the GynecoIogicaI ward of the Cook County HospitaI on JuIy 20, 1944. She spoke no EngIish and data were obtained from her husband who spoke EngIish poorIy. She apparentIy was in fairIy good health unti1 one year ago when she noticed vagina1 bIeeding and “something buIging” through the vagina and between her thighs. She passed her menopause at the age of fifty. Her bIood pressure was I 16/60; hemoglobin 80 per cent; red blood ceIIs, 3,850,ooo; white bIood ceIIs, 8,850; urine examination showed aIbumin o, sugar o, casts o.
of Uterus
MAY.1946
The externa1 genitaIia were atrophic. BarthoIins, Skenes, and urethra were negative. There was a Iarge necrotic mass protruding from the vagina measuring the size of a Iarge orange which was eIongated. To the right of the midIine of this mass there was another adherent decomposed necrotic tumor measuring about 4 by 4 cm., the center of which appeared “cooked” while the periphery was yeIIowishgreen. It was friabIe and bIed easiIy on sIight touch. The whole protruding mass was markedIy edematous and it was impossibIe to reduce it back into the vagina. A preoperative diagnosis of chronic uterine inversion was made, accompanied by a degenerating fibromyomas. However, malignancy was considered as a probabiIity. A vagina1 hysterectomy was done on August 31, 1944, and histoIogic sections proved it to be a hbrosarcoma. CONCLUSIONS
Uterine fibromyomas may undergo maIignant transformation. Statistica data were presented. Intrauterine neopIasms predispose to a possibIe spontaneous uterine inversion. A case is presented in which the chronic inversion was associated with fibrosarcoma. REFERENCES I. NOVAK and ANDERSON. Am. J. Obst. CY Gynec., 34: 740. 1937. 2. EVANS, N. Malignant myomata. Surg., Gynec. CY Obst., 30: 225, 1920. 3. KIMBROUGH, R. A. Sarcoma of uterus. Am. J. Obst. +Y Gynec., 28: 723, 1934.
B
J.
REICH,
M.D.
OF THE UTERUS WITH OF THE CORPUS*
AND MITCHELL J. NECHTOW, M.D. CHICAGO, ILLINOIS
the origina neopIasm is not The gross appearance of the neopIasm too common, and because of the wiI1 vary; however, the usua1 site for unusual conditions present in this sarcomatous degeneration is in the center case, we considered it worthy of reporting. of fibromyomas. In the usua1 benign Sarcoma of the uterus is not common, it fibroid of the corpus the tissue is hard, is indeed much less frequent than carcinoma gIistening, and has the circuIar or whor1 of the corpus. Among various chnics and appearance when the tumor is cut; but in reports, about 3.5 to 4 per cent of uterine the sarcomatous changes, the tissue appears mahgnancies are sarcomatous. Novak and necrotic or “ cooked.” Anderson1 found that in a period of twentyMicroscopically, the sarcomatous changes five years they encountered onIy fifty-nine are very much the same as those of sarcoma cases of sarcoma of the uterus in compariin other parts of the body. The spindIe ceI1, son with I ,263 cases of various other uterine round ceI1, and various mixed-ceI1 types maIignancies. are the usua1 findings. However, Novak, It was C. Meyer and Rudolph Virchow Evans,2 and Kimbrough3 beIieve that the who in 1860 presented the first case of a degree of mitotic activity may reffect the uterine sarcoma before the obstetrica severity of the maIignancy and its cIinica1 society of BerIin. Since then, some eightyprognosis. five years, the subject of uterine sarcoma The incidence of sarcomatous degenerais stiI1 in need of additiona discussion and tion of fibromyomas is probabIy .5 to I per enlightenment. cent. Novak’s findings are about as above The majority of clinics agree in their whiIe KeIIy and CuIIen in rgog, found statistica figures that the reIationship about 1.2 per ‘cent; other cIinicians and between sarcoma and carcinoma are about pathoIogists range from .5 to 4 per cent. I to 30 or 40. The greatest age incidence is Kimbrough3 states that sarcoma originthat during or after the menopause. Its ating from fibromyomas bear a much metastases wiI1 find other organs via the brighter prognosis than the primary sarbIood stream, the Iymphatics, or by direct coma; and in his experience the favorabIe extension. The Iiver and Iungs are the ratio was 3 to I. commonest sites for metastases; however, The primary sarcomas originated in other organs, such as the brain, ovary, and about 75 per cent of women who were in kidney may aIso be invoIved. the postmenopausa1 age, and onIy IO per There is no specific prediIection for any cent in younger women. Because of this, race or coIor and no definite hereditary the incidence of cures are Iess during the factors. menopausa1 age as compared with the Pathology. WhiIe sarcoma of the uterus younger women. may arise from the muscle fiber of the An interesting and ingenious prognostic uterus, the connective tissue, or the endomethod of Evans2 and corroborated by metrium, the commonest source is the Kimbrough3 in reIation to the number of fibromyomas of the uterus. Our case deaIs mitotic figures per cubic mm. of tissue as to the severity of the maIignancy, can be with the Iatter type. ECAUSE
* From The Department of Gynecology, Cook County HospitaI and The Cook County Graduate School; from The Hektoen Institute for Medical Research, and from the Service of E. W. Fischmann, M.D., Chicago, Illinois. 710
VOL. LXXI,
No.
3
Reich,
Nechtow-Inversion
appIied to the sarcomas, both primary and secondary types. It may be stated that the mpre mitotic figures, the more maiignant is
FIG. I. Original photograph of inversion showing tumor mass with patient in lithotomy position.
FIG. 3. Microscopic
of Uterus
7I 1
not characteristic and the diagnosis is usuaIIy made during or after surgery or histoIogicaIIy. However, abnorma1 uterine
FIG. Z. Original
sections
the neopIasm ; the fewer or absence of mitotic figures Ieads to a Iess maIignant growth and consequentIy a better outIook. Symptomatology of uterine sarcoma is
A merican Journal of Surgery
photograph showing and tumor mass.
inversion
of fibrosarcoma.
b1ee d’mg during or after the menopause, especiaIIy when associated with fibroids, should make one suspicious of a probabIe sarcoma of the uterus. Also, an abnorma1
7 12 American Journal of Surgery Reich,
Nechtow-Inversion
Ieukorrhea in a patient with fibroids which may or may not be bIoody shouId give rise to a possibility of sarcoma uteri; and if the discharge becomes fouI due to decomposition of tissue or necrosis, it may aIs point to sarcoma. We observed a case in which abnormaIIy fast growing myomas proved to be sarcomatous. Our case of uterine fibrosarcoma was complicated by compIete chronic uterine inversion. Non-puerpera1 uterine inversions are usuaIIy caused by some sort of neopIasms of the fundus. These tumors by means of traction and in the presence of a reIaxed uterine waI1 wiI1 create an inversion. It is reasonabIe to assume that without the reIaxed uterine waI1 a spontaneous inversion is aImost impossibIe. Fibromyomas are the commonest tumors associated in a nonpuerpera1 inversion. CASE
REPORT
Mrs. J. S., No. 28928, age seventy-six, was admitted to the GynecoIogicaI ward of the Cook County HospitaI on JuIy 20, 1944. She spoke no EngIish and data were obtained from her husband who spoke EngIish poorIy. She apparentIy was in fairIy good health unti1 one year ago when she noticed vagina1 bIeeding and “something buIging” through the vagina and between her thighs. She passed her menopause at the age of fifty. Her bIood pressure was I 16/60; hemoglobin 80 per cent; red blood ceIIs, 3,850,ooo; white bIood ceIIs, 8,850; urine examination showed aIbumin o, sugar o, casts o.
of Uterus
MAY.1946
The externa1 genitaIia were atrophic. BarthoIins, Skenes, and urethra were negative. There was a Iarge necrotic mass protruding from the vagina measuring the size of a Iarge orange which was eIongated. To the right of the midIine of this mass there was another adherent decomposed necrotic tumor measuring about 4 by 4 cm., the center of which appeared “cooked” while the periphery was yeIIowishgreen. It was friabIe and bIed easiIy on sIight touch. The whole protruding mass was markedIy edematous and it was impossibIe to reduce it back into the vagina. A preoperative diagnosis of chronic uterine inversion was made, accompanied by a degenerating fibromyomas. However, malignancy was considered as a probabiIity. A vagina1 hysterectomy was done on August 31, 1944, and histoIogic sections proved it to be a hbrosarcoma. CONCLUSIONS
Uterine fibromyomas may undergo maIignant transformation. Statistica data were presented. Intrauterine neopIasms predispose to a possibIe spontaneous uterine inversion. A case is presented in which the chronic inversion was associated with fibrosarcoma. REFERENCES I. NOVAK and ANDERSON. Am. J. Obst. CY Gynec., 34: 740. 1937. 2. EVANS, N. Malignant myomata. Surg., Gynec. CY Obst., 30: 225, 1920. 3. KIMBROUGH, R. A. Sarcoma of uterus. Am. J. Obst. +Y Gynec., 28: 723, 1934.