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Large cystic granulosa cell tumor: Case report
Large cystic granulosa cell tumor: Case report Chang-Hyuu M. Choi, MD, and James R. Pritchard, DO Massillon, Ohio This is a case of a large granulosa cell tumor of the ovary. The patient was a 42-year-old, white woman, gravida 1, para 1. The family claimed that she had a ''water tumor" in her abdomen. The patient was afraid of seeing a doctor. She died at home without any medical attention. During autopsy we removed approximately 20 gallons of turbid reddish brown fluid from the cystic tumor. The tumor's cystic wall and the fluid weighed approximately 77 kg (170 pounds). No metastasis was found in any other organs. (AM J OesTET GVNECOL 1990;163:74-6.)
Key words: Granulosa cell tumor, ovary
A case of a large granulosa cell tumor of the ovary is described. The woman failed to seek medical attention.
Case report A 42-year-old white woman, gravida 1, para 1, was found dead in her apartment. During the last 3 days before her death, she had not moved at all and sat in a chair clutching a baby blanket. According to the famFrom the Stark County Coroner's Office. Received for publication October 27, 1989; revised January 8, 1990; accepted January 18, 1990. Reprint requests: C. M. Choi, MD, Stark County Coroner's Office, 400 Austin Ave. N. W., Massillon, OH 44646. 611119485
ily, they, along with the patient, noticed the growth in her girth 6 months previously but she failed to seek medical attention. Her medical history was unremarkable other than "not feeling good." She was not taking any medications. When the body arrived in the Stark County Coroner's morgue, an autopsy was performed. The physical examination showed a well-developed, well-nourished white woman. The breasts were well developed and normal axillary and pubic hair was present. The upper extremities did not show pitting edema; however, the lower legs and feet revealed pitting edema (4 + ). The abdomen was extensively distended with the girth at the umbilicus measuring 168 cm (66 inches) (Fig. 1). The external genitalia were unremarkable. The skin on the back and abdomen showed irritated and eczematous changes.
Fig. 1. Girth was 168 em (66 inches), and approximately 76 L (20 gallons) of fluid was removed.
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Volume 163 Number I. Part I
Fig. 2. Tumor cells have scanty cytoplasm. Nuclei are oval with prominent nuclear grooves (coffee bean-shaped nuclei). (Original magnification x 400.)
Fig. 3. Several Call-Exnar bodies are present. (Original magnification x 200.)
Before we opened the abdomen, the fluid was drained . There was approximately 76 L (20 gallons) of turbid reddish brown fluid. On opening the abdomen virtually the entire abdominal cavity and part of the pleural cavity were replaced by a cystic tumor mass. The inner surface of the cyst wall was necrotic, hemorrhagic, and irregular. The cyst measured approximately 56 cm (22 inches) in greatest diameter. The cyst wall measured I to 2 cm in thickness. The outer surface of the cyst was pink and glistening. The heart, lungs,
and other organs were displaced and compressed by the large ovarian cystic tumor. The mass arose from the right ovary. The left ovary and uterus were within normal limits. Histologically, the wall of the ovary and cyst showed oval hyperchromatic cells with scanty cytoplasm. Many cells showed nuclear grooves (coffee bean-shaped nucleus) (Fig. 2). Numerous Call-Exner bodies were present (Fig. 3). Sections from the endometrium showed adenomatous hyperplasia with focal cystic changes. The
Choi and Pritchard
tumor was probably functional because of the presence of adenomatous hyperplasia with focal cystic changes in the uterus. No other organs showed evidence of metastasis. Comment In 1939, Drs. Dockerty and McCartneyl reported on large granulosa cell tumor of the ovary, which weighed approximately 35 pounds. In 1971, Drs. Robertson and Miller2 reported on a massive cystic granulosa-theca cell tumor that weighed approximately 150 pounds. We describe almost the same size of tumor; however, ours
July 1990 Am J Obstet Gynecol
is slightly larger than the most recent case. We believe our tumor is the largest recorded tumor of the same type. We are grateful to Brenda L. Sherrod for providing assistance. REFERENCES 1. Dockerty MB, McCartney WBC. Granulosa cell tumors. AM
J OBSTET GYNECOL
1939;38:698.
2. Robertson MG, Miller REC. Massive cystic granulosa-theca cell tumor: report of a case. AM 1971;110:407-9.
J
OBSTET GYNECOL
5-Fluorouracil exposure during the period of conception: Report on two cases Lawrence D. Odom, MD," Leo Plouffe, Jr., MD, eM," and William J. Butler, MDb Augusta, Georgia, and Albany, New York Two patients who were administered topical vaginal 5-fluorouracil for human papilloma virus lesions became pregnant during treatment. The outcomes in both cases were healthy with normal developmental landmarks at 6 months of age. This experience highlights the potential for a positive outcome. (AM J OBSTET GVNECOL 1990;163:76-7.)
Key words: 5-Fluorouracil, periconceptual exposure
The incidence of lesions associated with human papillomavirus has increased dramatically in the past two decades. The treatment of these viral lesions has proved to be associated with recurrence in 10% to 35% of cases. Consequently, adjuvant or prophylactic use of 5fluorouracil (5-FU) intravaginal therapy is becoming a widely accepted protocol. An obvious sequela of this new protocol is unexpected periconceptual exposure of the developing embryo to 5-FU, an antideoxyribonucleic acid chemotherapeutic agent. We present two cases of exposure during this period that resulted in two healthy, thriving infants.
From the Reproductive Endocrine Section, Department of Obstetrics and Gynecology, Medical College of Georgia: and the Reproductive Endocrinology Section, Department of Obstetrics and Gynecology, ALbany Medical College.' Received for publication September 22, 1989; revised January 29, 1990; accepted February 9, 1990. Reprint requests; Leo Plouffe, Jr., MD, Department of Obstetrics and Gynecology, Reproductive Endocrine Section, Medical College of Georgia, Augusta, GA 30912. 611120000
76
Case report Patient 1. A 26-year-old gravida 3, para 1-0-1-1 patient was first diagnosed and treated for genital condyloma at age 19 years. She had a history of regular 28-day cycles. Conization of the cervix was performed by laser vaporization after colposcopic examination and an abnormal biopsy specimen was obtained. The patient had daily application of approximately 65 mg of 5% 5-FU cream (Efudex, Roche Laboratories) to the vagina and cervix on cycle days 15, 16, and 17 for an estimated total of 185 mg of 5-FU. On approximately cycle day 31, the patient had positive results for ~ human chorionic gonadotropin. By the last menstrual period and ultrasonographic evaluation, the embryo was exposed between conception cycle day 15 and cycle day 21. Level II ultrasonography at 21.1 weeks' gestation revealed a normal anatomic survey. The maternal serum a-fetoprotein level was 48 ng/ml or 1.6 multiples of the median. The patient was delivered by repeat cesarean section at term of a 3720 gm male infant with Apgar scores of 9 at I and 5 minutes. No anomalies were noted by a consulting pediatrician. The infant's developmental milestones have been uneventful at 6 months of age.
Key words: Granulosa cell tumor, ovary
A case of a large granulosa cell tumor of the ovary is described. The woman failed to seek medical attention.
Case report A 42-year-old white woman, gravida 1, para 1, was found dead in her apartment. During the last 3 days before her death, she had not moved at all and sat in a chair clutching a baby blanket. According to the famFrom the Stark County Coroner's Office. Received for publication October 27, 1989; revised January 8, 1990; accepted January 18, 1990. Reprint requests: C. M. Choi, MD, Stark County Coroner's Office, 400 Austin Ave. N. W., Massillon, OH 44646. 611119485
ily, they, along with the patient, noticed the growth in her girth 6 months previously but she failed to seek medical attention. Her medical history was unremarkable other than "not feeling good." She was not taking any medications. When the body arrived in the Stark County Coroner's morgue, an autopsy was performed. The physical examination showed a well-developed, well-nourished white woman. The breasts were well developed and normal axillary and pubic hair was present. The upper extremities did not show pitting edema; however, the lower legs and feet revealed pitting edema (4 + ). The abdomen was extensively distended with the girth at the umbilicus measuring 168 cm (66 inches) (Fig. 1). The external genitalia were unremarkable. The skin on the back and abdomen showed irritated and eczematous changes.
Fig. 1. Girth was 168 em (66 inches), and approximately 76 L (20 gallons) of fluid was removed.
74
Granulosa cell tumor 75
Volume 163 Number I. Part I
Fig. 2. Tumor cells have scanty cytoplasm. Nuclei are oval with prominent nuclear grooves (coffee bean-shaped nuclei). (Original magnification x 400.)
Fig. 3. Several Call-Exnar bodies are present. (Original magnification x 200.)
Before we opened the abdomen, the fluid was drained . There was approximately 76 L (20 gallons) of turbid reddish brown fluid. On opening the abdomen virtually the entire abdominal cavity and part of the pleural cavity were replaced by a cystic tumor mass. The inner surface of the cyst wall was necrotic, hemorrhagic, and irregular. The cyst measured approximately 56 cm (22 inches) in greatest diameter. The cyst wall measured I to 2 cm in thickness. The outer surface of the cyst was pink and glistening. The heart, lungs,
and other organs were displaced and compressed by the large ovarian cystic tumor. The mass arose from the right ovary. The left ovary and uterus were within normal limits. Histologically, the wall of the ovary and cyst showed oval hyperchromatic cells with scanty cytoplasm. Many cells showed nuclear grooves (coffee bean-shaped nucleus) (Fig. 2). Numerous Call-Exner bodies were present (Fig. 3). Sections from the endometrium showed adenomatous hyperplasia with focal cystic changes. The
Choi and Pritchard
tumor was probably functional because of the presence of adenomatous hyperplasia with focal cystic changes in the uterus. No other organs showed evidence of metastasis. Comment In 1939, Drs. Dockerty and McCartneyl reported on large granulosa cell tumor of the ovary, which weighed approximately 35 pounds. In 1971, Drs. Robertson and Miller2 reported on a massive cystic granulosa-theca cell tumor that weighed approximately 150 pounds. We describe almost the same size of tumor; however, ours
July 1990 Am J Obstet Gynecol
is slightly larger than the most recent case. We believe our tumor is the largest recorded tumor of the same type. We are grateful to Brenda L. Sherrod for providing assistance. REFERENCES 1. Dockerty MB, McCartney WBC. Granulosa cell tumors. AM
J OBSTET GYNECOL
1939;38:698.
2. Robertson MG, Miller REC. Massive cystic granulosa-theca cell tumor: report of a case. AM 1971;110:407-9.
J
OBSTET GYNECOL
5-Fluorouracil exposure during the period of conception: Report on two cases Lawrence D. Odom, MD," Leo Plouffe, Jr., MD, eM," and William J. Butler, MDb Augusta, Georgia, and Albany, New York Two patients who were administered topical vaginal 5-fluorouracil for human papilloma virus lesions became pregnant during treatment. The outcomes in both cases were healthy with normal developmental landmarks at 6 months of age. This experience highlights the potential for a positive outcome. (AM J OBSTET GVNECOL 1990;163:76-7.)
Key words: 5-Fluorouracil, periconceptual exposure
The incidence of lesions associated with human papillomavirus has increased dramatically in the past two decades. The treatment of these viral lesions has proved to be associated with recurrence in 10% to 35% of cases. Consequently, adjuvant or prophylactic use of 5fluorouracil (5-FU) intravaginal therapy is becoming a widely accepted protocol. An obvious sequela of this new protocol is unexpected periconceptual exposure of the developing embryo to 5-FU, an antideoxyribonucleic acid chemotherapeutic agent. We present two cases of exposure during this period that resulted in two healthy, thriving infants.
From the Reproductive Endocrine Section, Department of Obstetrics and Gynecology, Medical College of Georgia: and the Reproductive Endocrinology Section, Department of Obstetrics and Gynecology, ALbany Medical College.' Received for publication September 22, 1989; revised January 29, 1990; accepted February 9, 1990. Reprint requests; Leo Plouffe, Jr., MD, Department of Obstetrics and Gynecology, Reproductive Endocrine Section, Medical College of Georgia, Augusta, GA 30912. 611120000
76
Case report Patient 1. A 26-year-old gravida 3, para 1-0-1-1 patient was first diagnosed and treated for genital condyloma at age 19 years. She had a history of regular 28-day cycles. Conization of the cervix was performed by laser vaporization after colposcopic examination and an abnormal biopsy specimen was obtained. The patient had daily application of approximately 65 mg of 5% 5-FU cream (Efudex, Roche Laboratories) to the vagina and cervix on cycle days 15, 16, and 17 for an estimated total of 185 mg of 5-FU. On approximately cycle day 31, the patient had positive results for ~ human chorionic gonadotropin. By the last menstrual period and ultrasonographic evaluation, the embryo was exposed between conception cycle day 15 and cycle day 21. Level II ultrasonography at 21.1 weeks' gestation revealed a normal anatomic survey. The maternal serum a-fetoprotein level was 48 ng/ml or 1.6 multiples of the median. The patient was delivered by repeat cesarean section at term of a 3720 gm male infant with Apgar scores of 9 at I and 5 minutes. No anomalies were noted by a consulting pediatrician. The infant's developmental milestones have been uneventful at 6 months of age.