Folliculoid Cancer of the Ovary with a Consideration of Ovarian Neoplasms in the Light of Histogenic and Morphologic Correlations

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The Kielland operation is not au operation i’trr all cases of procidcntia, Inat when indicated it is not difficult to perform. In doing the customary interposition :tperstion, I also 20 a high amputation of the cervix, and if the uterus is too large I take out a piece of the fundus, or a wedge from the whole uterus. 1 do not, recall an instance in which there was a recurrence. If the operation is adjust,cd to the condition, and not the condition to the operation, I lravc been able to get good results.

entitled Folliculoid Cancer of the Ovary with a Consideration af Ovariaa~ J!&wp&wxngih the Light of Histoigenic and Morphollogic Correlations. (See page 581.1

DR. MEYER R. ROBINSONread a paper

DISCUSSION Dr. I. C. RUBIN.-The subject presentesd is still debatable ground. Dr. Robinson deserves a great deal of credit for having again brought up the subj& and for having gone into the histogenetic phases. There are four types of epithelial structures that we must consider: (1) The germinal or surface epithelium; (2) The epithelium of the graafian follicles ; (3) The epithelium of the medullary cords; (4) The epithelium of the epoSphoron or parovarian ducts in the mesovarium. Dr. Robinson agrees with Robert Meyer that of all the possibilities presented by the epithelium in these various locations, it is most probably the epith’elial clumps of granulosa rests that have invaded the depths of the ovary and remain there for a long time which offer the basis of the carcinoma. If we &!eaJwith the Cehnheim theory then me may assume that these rests of the epithelium, embryonal in character, may at some time form the basis of carcinoma. The term ‘ t folliculoid carcinoma” is simply a descriptive term, rather than implying that the follicular part comes from the graafian follicle. What Dr. Robinson has described suggests atill another possibility, a new histogenetic type described by J. A. Sampson in a remarkably thorough and convincing report. Sampson has shown by a study of 137 cases, with most careful pathologic examinations, that tubal epithelium may be dislocated and become implanted on the ovary, uterus, peritoneum, appendix, etc. Dr. Jacobson, of Sampson’s Laboratory has taken bits of endometrial epithelium and implanted it in the serosa and has produced implantation adenomata or cystadenomata. I think we can accept these adenocystomata a8 arising from imThey become invasive and may lodge within the plantation of tubal epithelium. parenchyma of the ovary for a long time Instead of calling, upon a heterotopy to explain the earcinomatous convex&Km, we have a tissue closer at hand to serve as a In other words we cannot escape the imbasis for the malignant degeneration. pression that the adenocarcinoma of the ovary may arise from implants of the If we add to these four possibilities mentioned endometrium or tubal epithelium. by Dr. Robinson this new idea of Sampson’s, we have all the sources from which t& foll~ubid ovarian carcinomamay emanate. Dr. Sampson states that he u two caejes of carcinoma which he believes have this origin. We are indebted to Dr. Robinson for bringing this up, for while it does not settle the question it has aroused our interest in this subject dealing as it does with a unique pathologic lesion in one of the most complex organs in the body. DR. EMIL ,$KXD’T&l$7i.-The question of histogenesis is dif6cult to decide UpOn without close examination of the microscopical slides. I should like to ask Dr. Robinson if the centers of the eylindroid structures wsere blood VesSels. DR. ROBINSON.-Yes,

they were.

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DR. SGBWARZ.-Then this corresponds to the description of cylindromata given by Billroth. We might assume that this carcinoma is derived from the follicular epithelium, although connecting links have not been established between the two histological formations. Dr. Robert Meyer assumed that the origin of these tumors was from stray medullary tubules or strands very often found in the ovaries of adult women, since the fully developed follicular epithelium cannot be regarded as a source of such tumors, according to all experiences in oncology. It is, however, important to know that such tumors, after a careful search, sometimes show portions with distinct papillary structures, thus revealing their identity with other tumors of the papillary type. We are, in most cases, used to the exophytic growth of epithelium while these tumors show an endophytic proliferation. To a certain extent it is irrelevant whether histogenesis assumes the derivation from the germinalepithelium, as in the case of papillary tumor, or from medullary strands, as Dr. Robert Meyer and Dr. Robinson assert since both epithelial types are embryologically identical. There seems to be tho one difference that the period of development of the mother epithelium is different. DR. G. L. MORNGIL-Despite all work done so far we still know practically nothing at all of the histogenesis of ovarian tumors. As an example I may cite the Zeitschrift fiir Gynekologie and the Beitraege zur Geburtshilfe und Gyn& kologie for 1915. In the former journal Bauer “proved” by serial sections that pseudomucinous cysts came directly from invaginations of the surface epithelium of the ovary. In the second periodical Lahm, Kehrer’s assistant in Dresden, “proved” also by serial sections that these tumors had their origin in Walthard’s cell rests. We must avoid judging the origin of a tumor from its form alone. Again we must not stress a palisade or radial arrangement of the cells too much as we see it around blood and lymph vessels or on the periphery of alveoli in adenocarcinoma. Gottschalk years ago described a perithelioma of the uterus. Perithelium, however, has not been proven to exist in the uterus and an exaot duplicate case in my own experience some years later proved to be a carcinoma on serial section. The peculiar structure was simply due to the fact that the tumor was growing around lymph-vessels or perivascular lymph spaces. I have seen two cases of what at first appeared to be folliculoma ovarii and one of these proved on closer examination to be nothing more than a carcinoma growing around lymph channels. The coagulated lymph and degenerated cells simulated follieular structures to some extent. We must not forget that the ovary is the exact homologue of the testicle and originally develops the same excretory system of tubules. The process of extrusion of the ovum has however become reversed and occurs by means of rupture of the follicle. The whole excretory apparatus hence becomes useless and we have a lot of “dead”, that is, functionless tissue, in the ovary from any part of which a tumor may develop. I do not believe, however, that, for the present at least, any one can tell which type of tumor is derived from any particular part of the ovarian structures. One thing only seems certain and that is, as Dr. Robinson has said, that the mature follicles and granulosa certainly do not develop into these folliculomata. Perhaps further research may show that these tumors are not really histogenetically different from other tumors of the ovary but merely an atypical form of some other well known tumor of frequent occurrence. DR. ROBINSON, (closing).-Dr. Rnbin’s hyp80thesis, based upon the recent work of Sampson, that folliculoid cancer of the ovary may also have an endosalpingial or endometrial genesis, is hardly acceptable. A critical s,tudy of Dr. Sampson’s contribution has convinced me that his adenomatous formations differ in no way from those that I have described in 1913 in my study of “Adenomyo salpingitis ’ ’ and that most of them or all of them are secondary to inflammatory processes. I have often seen such formations in eases of perioophoritis. Furthermore,

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in order to correspond to the Sampson theory, folliculoid cancer ought t,o start from the surface of the ovary where the uterine or tubal epit,heBum is tirst d:: posited. In my specimen the ovarian cortex was well retained and was free From any tumor invasion; the new growth has chiofly involved the deeper portions. Xoi are there any other morphologic evidences in folliculoid or cylindroid cancer to link it to the Sampson theory, for in adenomatous formation we see an invasion of the normal stroma by these glands, sparsely in the beginning and more extensive later on. Here the normal tissues are reptaced by an excessive proliferation of round epithelial cells and only hero and there do some of these cells group themselves into gland-like forms, and these cells bear no resemblance to the endometrial or the endosalpingial epithelium. Dr. Schwarz’s endothelial suggestion would be acceptable if our specimens would show any intravascular or extravascular endothelial proliferations. While the connective tissue scpta do show an abundance of capillaries, they do not in any way form angioplatic tumors and the endothelium remains normal. I did not expect unanimity on this question of the histogenesis of folliculoid cancer of the ovary. This chapter, as well as the one on ovarian tumors in general will undoubtedly remain open for many years to come, but what I wish to impress by this study, and by the rest o-f my paper, which due to lack of time I did not read, is that in discussing the pathology of ovarian tumors we must always attempt to correlate histogenesis wit,11 morphology, aud not permit the latter to sway our pathologic diagnosis,