Fibroma of the ovary

BRODT :

521

OF OVARY

FIBROMA

SUMMARY

This is a report of a caseof successful childbearing following an operation for the construction of an artificial vagina in a patient who presented the following anomalies : Agenesia of the vagina, left tube and ovary, left round ligament, left infundibulopelvic and left uterosacral ligaments, together with agenesia of left kidney and the presence of an abdominal ninth rib on the left side. In this case the Graves! operation for the construction of an artificial vagina was eminently successful, although a modification in the technique has been suggested. The patient is now pregnant for the second time. It is very important in the aftercare of patients operated upon for vaginal agenesis to stretch the artificial vagina twice weekly for six months. If they are married they should have coitus twice weekly during this time. The tendency to contra&ion of the artificial vagina, however, is over at the end of six months. REFERENCES 1. 2. 3. 4. 5.

Word, B.: South. M. J. 33: 293, 1940. \ Varino, G. A., and Beacham, W. D.: AM. J. ORST. & GPNEC. 41: 124, 1941. Wharton, L. R.: Surg., Gynec. & Obst. 40: 35, 1925. Graves,
AVENUE

FIBROMA

OF THE OVARY

SIMOK BRODY, M.D., BROOKLTS, (From

the Gyn.ecologicnl

Serrice

of

the Beth

W. T. Moses

Hospital)

tumors are very often associated with ascites. In cases of ovarian fibroma, the ascites is sometimes accompanied by hydro0thorax.VARIAN This symptom complex was first described by Meigs and Cassland In his original resince then has been known as “l\leigs’ Syndrome.” port Meigs stated that he had no adequate physiologic explanation for this phenomenon. Bomze and lGrschbaum2 suggested that the ascites and pleural effusion may be the result of a low-grade cardiac decompensation in a patient who has a subclinical or compensated cardiac weakness in which the cardiac reserve is just sufficient to withstand the strain of the patient’s activities. The added stress thrown on the heart by the pressure of the heavy ovarian fibroma., combined with its possible interference with pelvic and lower abdominal circulation, may be sufficient to produce the low-grade cardiac decompensation. This view does not account for the fact that often the tumor may be small, hardly sufficient to interfere with the circulation by virtue of its weight or size. Neither does it explain the fact that the mere removal of the tumor is sufficient to bring about the disappearance of all the fluid as well as the complete recovery of the patient without any treatment being directed toward the cardiovascular system. It would seem that the accumulation of fluid in t,he abdominal and thoracic cavities of patients with ovarian fibroma is not due to any

interference with the circulation but t)ossibly lo a disturbance ill the water metabolism. This opinion is substantiat cd by the ease relmrted here, whew. in the presence of a very large ovarian fibroma, 1here was a fair amount of fluid in the peritoneal eavit! its ~(‘11 as a markc’cl SII~)cutaneous edema confined only to the region 05 Ihe lower ahclomen. There was no edema of the lower extremities and no evidence of hydrathorax. In the nbsenc~c of an;\- cridenec of tardiovascular pathology, a localized edema of such nature may be clue IO some clisturbancc in the water balance of the system.

I’. S., a &year-old colored female, was admitted to the Beth Noses Hospital on Narch 4, 1941, with a history of irregular vaginal bleeding, weakness, and loss of weight. Two >-cars ago her menstrual period, which was on time, lasted for twelve clays instead of the usual five days; it was very ~rofusc and was accompanied by passage of clots. 8he was admitted to the Kings County Hospital, Brooklyn, where she was toll1 that she had a tumor. When the bleeding ceased, she signed a releasch. Three months later the patient had another episocle of bleeding w&h passage of clots, lasting for one week. Since that time she has mcnstruated about. every t,wo months? the flow lasting from seven to eight days; it was very profuse with passage of elois. There was no dysmenorrhea. Three lveeks prior to admission she felt dizz,v and developed a slight cough. One clay later she had a water>- vaginal discharge. Eight days later she began to bleed profusc~ly, the bleeding persisting until admission to the hospital. The pat,ient was a gravida ix, para vi. She had had three miscarriages following the birth of her first child. Her youngest child was thirteen y-ears old. The pat,ient’s menses startecl at the age of 13, occurred every thirty days, and IWed for five days. There was no dysmenorrhea or leucorrhca. The patient. was suffering from constipation, her appetite was poor, and she had lost SO pounds during the past gear. Physical examination revealed an aeutclv ill woman. cachectic and pale. Her blood pressure was 135 systolic and 76 diastolic. Heart esamination revealed essentially negat,ivc findings. The lungs revealed the breath sounds clear. There were no r$les or evidence of any fluid in the thoracic cavity. Abdominal examination revealed a visible and palpable mass filling the entire abdomen from the symphysis to the ensiform. The mass was slightly movable, hard. nodular, and not tender. The skin over the lower abdomen was lcalhery in consistency and edematous with marked pitting on lnessurc. Thcie were dullness, anteriorly a,ntl tpmpany in the flanks. There was no evidence of shift,ing dullness. There was no edema of the legs. Vaginal examination revealed a multiparo~ls out,let. The cervix was high in the vault, of the vagina; it wa.s lacerated, movable, ancl not tender. The uterus could not be felt independently of the abdominal mass. The adnesa could not he palpated. The general appearance of the patient, the anemia. the loss of weight, ancl the nodular feel of the abdominal mass suggcst,cd the pwsence of an ovarian malignancy. Lnhorc/for,!/ Fi)lfGlqs.-I’rine was esscntiallv negative. Blood count revealed hemoglobin 6 Cm. per 100 c.c.; red blood rount, 2.470,OOO: white blood count, 10,200; polgnuclear lencocytcs, 65 per rent: and Ivmphocytes, 35 per rent. Wassermann and Kahn tests were negative.

BRODT:

FIBRONA

OF

OCART

523

Blood chemistry revealed sugar S5 mg., urea nitrogen 8 mg., and chlorides 470 mg. The patient received two transfusions of 500 e.c. each on the third and fifth days of her stay at the hospit,al. Her hemogIobin then rose to 9 Gm. per 100 C.C. and red blood count to 3,TSO,OOO. Two days later a laparotomy was performed. At operation marked edema of t,he subcutaneous fat was found. There were about 500 C.C. of straw-colored fluid in the peritoneal cavity. The left ovarian tumor was the size of a basketball; it was twisted upon its pedicle and was solid in consistency, except for a few cystic areas. The uterus was slipht,ly enlarged. The right ovary was solid, the size of a hen’s egg. There was no evidence of any peritoneal or intestinal implantations.

Fig.

l.-Cross section c:rlity with

of left ovarian small endometrial

fibroma. polyp.

Uterus opened. exposing endometrial Cross section of right ovary.

In order to deliver the cyst, the abdominal incision had to be extended above and to the left of the umbilicus. The cyst ruptured at one point and some thick mucilaginous fluid escaped. A hysterectom;v and bilateral salpingo-ool~horectom~ were performed. The following is the pathologic report of the specimen, as described by Dr. A. R. ICantrowit,z: C*ross: Specimen consisted of a supracervically amputated uterus, together with both t.ubes and ovaries. The uterus was regular in size, measuring 6.5 by 6 by 4.5 cm. The endomctrial cavity measured 5 cm. in length. The endometrium presented a mottled hemorrhagic appearance. In the left posterior wall, 1 cm. from the fundus, there was a polppoid projection, 2 bp 1 cm. The polypoicl projection presented a The right tube measured 10 cm. in mottled hemorrhagic appearance. length; its fimbriated end was patent. The ovary measured 5.5 by 4 by 2.5 cm. It was firm in consistency and on crnss section was found to

524

AMERICAS

JOT-RSAL

OF

OBSTETRICS

AN)

GTSECOLO(:I

present a pearly-gray color with motlled yellow and tan areas. -1 cortical zone was rather well demarcated lIecause of the presence of nlmierThe left, tuhc measured 1.i cm. ous 0.2 to 0.3 cm. sized grayish nodules. in length; its fimbriat.etl end was also ~mtcnt. :t lappet of lissnia. 5 b> 3 by 2 cm., was adherent by l.uhoovarian ligameilt to the left tWbe. ( ‘!JIItiguous with this mass, but demarcatxd from it somewhat,, was a mass, 21 by 18 by 11 cm. This mass presented a smooth ~psnle. The surl’ac~~ vessels were distended and prominent, and a number of bosses, IY’J~IXsenting the domes of cysts and containing clear IO scrohemorrhagic ftuill. were noted. The remiindcr of the mass was solid cscc>pt for innumerable spongelike areas presenting a reddish gray color. The solid portions of the ma,ss presented a pearly gray color with circumscribed nodular arcas and whorls of t,issuc resembling a fibromyoma of the uterus. Thp left ovarian mass weighed 2,270 Gm. without fluid evacuated and lost cluring the Course of the operation.

Nict~oscopic: The endomctrium was in a stage of lbroliferalion. The polyp was composed of cndometriwl stroma and glands. The tubes showed no cssent,ial changes. The right ovary showed a hyprrplasia of the cort,ical layer. The mass in t,he left ovary was composed of intc,rlacing bundles of spindle cells. There was no atypism. _I rare mitotic figure u‘ns noted. Sudan st.ains ~csc&d no fats. I)o~~bI?--rcfrac~tilc bodies were not found. The van (litason and other fihrr stains revealecl only a collagen network of fibrils; no cytoplasmic network. -Ireas of degeneration and necrosis with cyst. formation wcrc noted. The lapl~et of left ovarian tissue was normal. Diag?zosis.-Large fib~om~ of the left ovary; hyperplastic right ovnry: proliferating cndometrium ; Graafinn l’olliclc ilcft ovar>- 1: cndometrial polyp. The patient’s postoperative stay in I hc hospital was longer than usl~al. There was a rise in her tempcrat,ure to 103.4” F. on the third day. This lasted for three days, subsiding after sulfathiazole medication. The

GOODWIN

:

SILATERAL

OVARIAN

DERMOID

525

CYSTS

The condition was diagnosed radiographically as a right pneumonitis. patient subsequently ran a subacute temperature from 100” to 100.2” F. due to an infection of the wound. This finally healed, and she was discharged from the hospital twenty-two days postoperatively in good condition. SUMMARY

1. A case of large fibroma of the ovary is reported. 2. In addition to a small amount of fuid in the abdominal cavity, the patient had a marked localized edema of the subcutaneous tissue of the lower abdomen. 3. The possibility of fibroma of the ovary causing a disturbance in water metabolism is postulated. 4. Patient’s history and clinical findings were strongly suggestive of malignancy. The value of surgery in cases thus diagnosed is once more emphasized. REFERENCES 1. Meigs, 2. Bomze,

J. V., and E. J., and

Cass, J. W.: Kirschbaum,

Au. J. OBST. J. D.: Ax J.

& GYNEC.

33:

249,

1937.

OBST. & GYNEC. 40: 381, 1940.

BILATERAL OVARIAN DERMOID CYSTS COMPLICATING PREGNANCY TREATED BY BILaTERAL OOPHORECTOMY’ ROBERT

H. Goonwr~;,t A.B., (From

the Obstetric

M.D.,

F.A.C.S., NEW

Sewice

o,f St. Luke’s

BEDFORD,

MASS.

Hospital)

F

ORTY-FOUR cases of bilateral dermoid cysts complicating pregnancy have been reported, of which 13 occurred during the first three months. In 1938 Bernard Notes1 of Washington, D. C., reported a case. He stated that a search of the literature revealed but 3 others. In 1940 Andrews and others2 of Norfolk, Va., reported a case and culled the literature to such an extent that they discovered 43 others, reports of some of which mere incomplete. In this presentation, I wish to offer the forty-fifth and the fourteenth during the first trimester. CASE

REPORT

Mrs. E. C., a 25-year-old primigravida, first presented herself at the office on March 16, 1940. Her last period was Jan. 19, 1940, making her due, by dates, Oct. 26, 1940. Her past history was negative. Her mother had died of intestinal cancer. Catamenia began at 12, occurred every thirty to thirty-five days with a scanty three-day flow, characterized by cramps and a bearingdown sensation premenstrually and on the first day of flow. Her last menstruation was a twenty-five-day interval period with the flow about half the usual amount. *Presented tin active

at a meeting of the service. U.S.N.R.

Obstetrical

Society

of

Boston,

January

20. lW?.