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Melanogenic ovarian tumors
Melanogenic ovarian tumors JOSE
F.
GEORGE
AFONSO, M.
FRANK
Seattle,
MARTIN,
S. NISCO,
RUSSELL
R.
M.D. M.D. M.D.”
DE ALVAREZ,
M.D.
Washington
MELANIN-PRODUCING ovarian tumors can be primary or secondary. Secondary melanogenic ovarian tumors are usually metastatic from malignant melanomas of the skin or choroid.l-10 Secondary melanomas of the ovary are not uncommon and at least 49 cases have been reported.l An additional 9 cases were described in which the ovarian metastasis assumed the form of a large homogenous tumor so that the preoperative diagnosis of primary ovarian neoplasm was made.5-10 Primary malignant melanomas of the ovary are rare. Review of the literature from 1900 through 1960 reveals only 8 cases in which the malignant melanoma may have been primary in the ovary. Three of these developed in dermoid cysts,11-13 and in the other 5 the melanoma did not seem to be associated with any teratomatous elements.l*-I8 When the melanoma was associated with the dermoid cysts, it appeared as a solid, nodular, black area in the cyst wall. The other tumors were mostly solid with lobulated external surface and of elastic or firm consistency. The cut surfaces were uniformly black or showed
islands of black tissue segregated by firm gray-white septa. The color of the external surfaces was uniformly or partly black, dark blue, or grayish brown. Two of these tumors were bilateraY7 l7 and 6 were confined to one ovary.11-15s I8 These tumors were freely movable except for occasional adhesions to the surrounding structures. The symptoms associated with these tumors were similar to those of other nonfunctioning ovarian tumors, and in one caseI the first symptoms were referable to a metastasis. Of these neoplasms only one was associated with pregnancy and was removed during the fourth month of gestation.14 The ages of the patients varied from 26 to 77 years. Malignant melanomas of the ovary are expected to be highly malignant, but no valid conclusions can be drawn in this regard from the cases recorded in the literature because both treatment and follow-up were inadequate. The treatment consisted of simple removal of the tumors in 2 cases,“) lfi unilateral salpingo-oophorectomy in one case,13 and in another bilateral salpingo-oophorectomy and subtotal hysterectomy.17 No treatment was mentioned in two reports,ll, l2 and in one report it was stated that no treatment was possible.15 In the last reported caseI the patient had had a subtotal hysterectomy and, when the ovarian tumor was found, bilateral salpingo-oophorectomy and omentopexy were performed, followed by postoperative x-ray irradiation. There was no follow-up in 3 cases.ll* 13, I6 Three patients were well, respectively, 3, 4, and 30 months after ther-
From the Department
of Obstetrics and Gynecology and the Department of Pathology, University of Washington School of Medicine, and the King County Hospital.
Supported in part by a training grant (CLT-7102) from the Cancer Institute, United States Public Health Service, and by a grant from the University of Washington Initiative 171 Funds for Research in Biology and Medicine. *National
Cancer
Institute
Trainee.
667
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apy.14.
17,
September 1, 1962 Am. J. Obst. & Gynec.
et al.
IS Of 2 patients known to have died, one survived 18 months after simple removal of the tumor,l? and the other was not treated and died 11 months after the onset of symptoms.15 The mode of spread of malignant melanoma of the ovary as judged by the cases reported is through the lymphatics (isolated right inguinal node metastasis in one caseI”) , blood stream (generalized osseous metastasis and liver metastasis in one patient,]’ isolated brain metastasis in another’“) and by continuity, with generalized abdominal melanomatosis or localized omental metastasis.“, Ifi Ovarian teratomas often include minor components which produce or contain melanin, representing adult structures that normally contain this pigment.1”-21 Considering that in ovarian teratomas the growth and development of some tissue is much greater than in that of others,l”-Z1 one can expect to find tumors in which the melanin-producing elements predominate. All such neoplasms previously
reported
lesion which benign.
we
have
been
report
here
malignant.
The
is apparently
Case report Present illness. Miss single, white nulligravida,
M. T., an 18-year-old,
King
March
County
Hospital
was
admitted
to
the
2, 1958, hecausc
of abdominal swelling of 9 months’ duration. She had heen well until June, 1957, when she noted left upper qtiadrant pain and hematemesis. Gastrointestinal findings were negative, and she received multiple transfusions. Ahdominal enlargement was noted at this time. She f<,lt well until August, 1957, when the hematemesis recurred and several blood transfusions wcrc required. Repeated gastrointestinal srrics showed no abnormalities. In October, 1957, the abdomen was found to he markedly distended, and on paracentcsis a black, watery, guaiac nrgative fluid was obtained. This fluid reaccumulated requiring repeated paraccntcses. The patient continued to lose weight and felt well except for the discomfort of recurrent abdominal enlargement. She had had a normal menarche at the age of 11, and the menses had been normal until July, 1957, when the cycles became irrc,gular. In October, 1957. she developed amenorrhea.
Past history and family history. Past history family history were both noncontributory. Physical examination. On admittance the patient appeared thin, pale, and chronically ill. The vital signs \vere normal. General physical rxamination showed only the following positive findings: there were marked abdominal distention and skin wounds from previous paraccnteses, the entire ahdomcn was flat to percussion and a fluid wave was present, and a slightly tender, 9 by 6
and
by 5 cm. firm, fairly smooth, partially
movable
mass filled the left upper quadrant. Laboratory and x-ray examination. On admittance thr, venereal disease laboratory tests wcrc nonrcactivc, the hcmatocrit reading was 23 per cent, and the white hlood cell count was 5,000 per cubic millimeter with a normal differential count. Srrum crcatinine, electrolytes, alkaline phosphatasc, bilirubin, serum total protein and protrin fractions wcrc normal. Clotting time, clot retraction and stability, and prothrombin timr: wcrf’ normal. The sulfobromophthalein and thymol turbidity trsts were normal and the cephalin flocculation test was 3-plus. Catheterized urine analysis and stool guaiac wcrc ncgativr. Bone marrow examination showed no abnormaliticzs except for depletion of iron stores. A chest film showcxd patchy atclectasis at the right has?, and a Hat plate of the abdomen showed ohlitcratlon of soft tissue sh adows. Uwcr gastrointestinal series revealed minimal lower esophageal varices and upward displacement of the stomach. An intravenous pyelogram drmonstrated right hydroureter and hydronephrosis. Hospital course. After admission a paracentesis was performed, yielding 9,300 ml. of India inklike fluid of specific Rravity 1.020, containing 1 white blood cell per 1 c.c., 204 mg. of protein per 100 c.c., and 3.5 units of amylasc activity per 100 c.c. After rc,moval of this fluid thrs upprr quadrant mass descended to the lrft parautnbilical r+ @on. A pelvic examination done at this time showed no abnormalitic~s. Rpd ccl1 and plasma volume< r&ctcd marked depletion of the red ccl1 mass, and thr patient was transfused with 5 units of packed ~11s. A sigmoidoscopic examination was negative, and csophagoscopy showed a hiatal hernia. Following a second paraccntesis and the removal of 2,250 nil. of black fluid, diatrizoatc methylglucamine (Rcnografin) was injected, and a flat plate of the abdomen showed the opaque material outlining a 12 by 24 cm. cystic structurcb lying anteriorly tn thr spinrx.
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Gynecologic consultation was sought. On March 19, 1958, an exploratory laparotomy was performed. All structures within the peritoneal cavity were variably covered and stained by a coal black, India ink-like fluid which made differentiation of the various structures extremely difficult. The spleen and the kidneys were normal to palpation. Filling the abdominal cavity was a 24 by 17.5 by 7.5 cm. cystic mass of grayish color, streaked with black pigment and of smooth contour except for a black 9 by 5 by 5 cm. firm component which occupied its left upper pole. During the dissection it became apparent that the tumor arose from and replaced the right ovary. The stomach and small bowel were displaced and compressed into the upper abdomen, and the colon partially circumscribed the tumor at its periphery. The tumor was adherent to the anterior abdominal wall and to the pelvic peritoneum. A few thin adhesions were present between the tumor and the liver. The liver was slightly enlarged and had an irregular hard nodular surface. Iliac and periaortic lymph nodes were enlarged, hard, and black. The uterine fundus was normal. Right salpingo-oophorectomy was performed. Frozen sections of omental and peritoneal nodules and of the tumor showed only heavily pigmented fibroadipose tissue and suggested that the ovarian tumor was either a pseudomucinous cystadenoma or a teratoma. Because of the apparent dissemination of the disease, no further surgical intervention was undertaken. The patient’s postoperative course was completely uneventful and she was discharged from the hospital on the tenth postoperative day to return to the care of her private physician. Subsequent course. Following discharge she felt well and resumed a normal menstrual pattern within 2 months. She was readmitted for evaluation on Sept. 20, 1959. Complete physical examination revealed as the only abnormality a 10 by 7 by 6 cm. cystic, nontender, movable mass in the left adnexal area. All the laboratory tests previously reported were repeated and found to be normal. A urine test for melanin was negative. The glucose tolerance test, protein bound iodine, and blood urea nitrogen were normal. Chest, skull roentgenograms, intravenous pyelograms, and upper gastrointestinal series showed no abnormalities. A Papanicolaou smear showed normal cells. Because the left ovarian cyst persisted and had enlarged slightly, an exploratory Iaparotomy was performed Dec. 29,
Melanogenic
ovarian
tumors
669
1959. When the abdominal cavity was opened, multiple patches of black pigment, up to an area of 4 by 5 cm. each, stained both the parietal and visceral peritoneum. Black staining of areas of the mesentery and appendiceal serosa were also noted. The pelvic peritoneum was aimost entirely black in color, and the serosa of all pelvic viscera was streaked with black pigment. The uterus appeared normal except for the coloration of its serosa, and the right tube and ovary were absent. The left ovary was replaced by a 6 by 10 by 6 cm. cystic tumor bound to the lateral pelvic wall by thin adhesions stained with black pigtnent in its outer surface. Both kidneys, adrenal glands, spleen, and liver were normal to palpation. There wrre no other abnormalities found in the abdominal cavity, and the periaortic lymph nodes appeared normal. The serosa of the liver was stained with black pigment in some areas but no nodules were now palpable. A left salpingo-oophorectomy, total hysterectomy, and appendectomy were performed, and several biopsies were taken from the parietal and pelvic peritoneum. The patient tolerated the operation well and recovered rapidly. When discharged she was advised to continue stilbesterol, 1 mg. daily, and has remained asymptomatic and entirely well qince. Pathologic studies. First
operation
(March
19, 1958).
The cystic, fluctuant right ovarian mass weighed 1,925 grams and was 24 by 17.5 by 7.5 cm. in over-all greatest dimensions (Fig. 1). Most of the surface was relatively smooth, glistening, and pink, except for tortuous streaks of black pigment, some of which appeared to outline blood vessels. Several solid, irregularlyovoid adherent nodules of black tissue were up to 2 cm. in greatest dimension. Adhering to the surface of the large cystic mass was a tubular structure resembling an oviduct; it was 10 cm. in length and averaged 0.6 cm. in diameter. An irregularly ovoid body of firm black tissue covered a portion of the main cystic mass. It was said to have occupied the left upper pole of the mass in situ. On cut section, it proved to be a discrete subsidiary mass, 9.5 by 5 by 5.2 cm., consisting of a central cavity 4.5 by 3.5 by 4.9 cm., surrounded by a discrete wall of firm black tissue, 0.6 to 1.3 cm. in thickness (Fig. 2). Except for a few streaks of gray, this wall was homogeneously black. The principal cystic portion of the mass contained more than a liter of thin, turbid, black, GROSS
EXAMINATION.
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Afonso et al.
Fig. 1. Gross appearance of tumor: external surface.
Fig. 2. Gross appearance of tumor: cut section, showing lining of large cyst and of subsidiary black mass.
Scptcmber 1, 1962 Am. J. Obst. & Gynec.
odorless fluid. The gray-tan cyst lining was relatively smooth, but finely “pebbled” and, in its collapsed state, grossly convoluted. A few scattered fine and coarse black markings and occasional cystic excrescences were present, the latter ranging up to 1.5 cm. in greatest dimension. The wall of the large cyst ranged from 1 to 10 mm. in thickness. MICROSCOPIC EXAMINATION. Forty-one samples from the formalin-fixed tissues were embedded in 27 paraffin blocks and stained with hematoxylin and eosin. All samples from the large cyst showed a lining of glandular columnar epithelium resembling gastrointestinal (Fig. 3), usually mucosa, particuIarly the pyloric region of the stomach. Many glands contained large eosinophilic cells resembling gastric parietal cells (Fig. 4). Some observers noted a resemblance of portions of this mucosal lining to cervical cpithelium. In several foci there was acute ulceration of the mucosa, with fibrinous exudation, hemorrhage, and young granulation tissue. The bulk of the wall of the cyst consisted of scanty cellular connective tissue, varying from loose, palely cosinophilic tissue with stellate fibroblasts to dense, compact hyaline material. Parallel strands and bundles of smooth muscles were found. Vascular channels were scattered throughout these tissues. Widely separated samples showed remnants of ovarian tissue in the form of intramural follicular cysts. A single maturing ovarian follicle was noted. Typical ovarian stroma was not found. Numerous isolated, discrete aggregates of melanin-containing tissue were noted which were usually ovoid in outline and varied from microscopic foci found just beneath the mucosal lining to the grossly noted black nodules projecting from the surface of the large cyst (Fig. 5). L4 few were in the midportion of the cyst wall. Invariably the dark brown to black, coarsely granular pigment was associated with dense sclerotic connective tissue, usually 3 palely cosinophilic tissue with scattered, rare, compact, deeply basophilic spindle-shaped nuclei. The pigment generally appeared to be depositrd in the stroma but in all nodules could also he found filling the cytoplasm of elongated spindle-shaped cells varying from about 20 to 40 p in length (Fig. 6). They were usually arranged in parallel layers and bundles. Their ovoid centrally placed nuclei were sharply outlined by the pigment. They contained little chromatin and typically possessed single, discrete, paracentric nucleoli. The nuclei were on the average
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Melanogenic
about 5 p in length. A minority of the pigmentcontaining cells had a rounded configuration and a disproportionately abundant cytoplasm. These cells were suggestive of macrophages. Perivascular aggregates of pigment were found throughout most of the adventitial tissues of the cyst. The cells containing this pigment were more typically of the macrophage configuration, but definite spindle forms could also be found. Abundant serosal perivascular intracellular deposits of brown and black pigment were also found in sections of an otherwise normal-appearing Fallopian tube. Scanty depositions of pigment were also noted in the lamina propria of the mucosal folds. The large, black, centrally cystic subsidiary mass was histologically quite similar to the smaller nodules found on and within the main cyst wall. The accumulation of melanin pigment was much more spectacular, however, there being large acellular pools of black pigment in what was apparently degenerated tumor tissue. Accumulations of unstained elongated spaces in these regions were suggestive of “cholesterol clefts.” A single, multinucleated foreign body giant cell was found in these tissues. It contained pigment and clefts. Fibrin strands adhered to the lining of the central cavitation. The black mass was densely adherent to th,: wall of the main cyst
Fig. 3. Portion (x100; reduced
of cyst wall I/*.)
ovarian
tumors
671
but was sharply delineated from this wall, usually by numerous flattened, elongated, apparently discontinuous cystic spaces which were lined by a single layer of small flat to cuboidal epithelial cells. A biopsy of an omental “node” contained superficial aggregates of large pigment-laden cells which seemed clearly to be macrophages. A biopsy of a hard anterior-wall peritoneal nodule consisted of sclerotic melanotic tissue quite similar to that found in the main mass. Both spindle-shaped and rounded cell types were included. HISTOCHEMICAL STUDIES. Prussian blue stains for iron were consistently negative, except for a very rare intracellular deposit of granular blue pigment. It was difficult to interpret argentaffin stains, since virtually all the pigment was already dark brown to black. In areas where the pigment was less dense, however, ammoniacal silver nitrate appeared to be reduced by the pigment, with the deposition of black metallic silver. The use of a strong oxidizing agent (10 per cent fresh H,O,) resulted in a gradual bleaching of pigment from black to brown to yellow to colorless in a period of about 24 hours. Unfortunately, oxidase activity of the cells could not be evaluated because of relatively prolonged formalin fixing.
lined by simple columnar
mucosecretory
epithelium.
672
Afonso
Fig. 4. Gastric wall, including (~440: reduced
et al.
glands large 9:. i
from pale
lining of portion globular parietal
of cyst cells.
CHEMICAL STUDIES. An aliquot of the coal black fluid from the main cyst was centrifuged and a large quantity of heavy, black precipitate was obtained. This pigment was highly insoluble in a variety of organic and aqueous solvents, including strong acids. It was slowly dissolved by 5 N NaOH. Ten per cent H?O, slowly bleached the pigment to a colorless product. When the pigment was examined under ultraviolet light, a dull green fluorescence was observed. Lyophilization of 420 ml. of this fluid resulted in 19.5 grams of pale gray powder. Two hundred and fifty milligrams per milliliter of aqueous solutions of this material were employed in Warburg manometric. studies designed to demonstrate oxidase activity. The main compartments of the flasks contained 1.6 ml. of the redissolved
lyophilized cyst fluid and 0.6 ml. of 0.2 M phosphate buffer. The side arms contained 0,6 ml. of substrate. The center walls contained 0.2 ml. of 10 per cent KOH. The following substrates were employed : ~-3, 4-dihydroxyphenylalanine I.-tyrosine, 5-hydroxytryptamine crca(DOPA), tine sulfate, and p-phenylenediamine. The final
Fig. 5. Convoluted, found in a solid large cyst. (x35:
organoid deposition of melanin fibrotic nodule on surface of the reduced ;C,.)
concentrations of substrate were 6 mM. except for r.-tyrosine, in which case saturated solutions were employed. The ph was 7.4 in the case of the first two substrates and 6.2 in the case of the last two substrates. Appropriate control flasks were prepared and the rate of oxygen consumption was observed at :3’i” C. for a period of 3 hours after a 15 minute equilibration period. No tyrosinase or DOPA oxidase activity could be detrctcd. In fact, the spontaneous oxidation of DOPA was markedly inhibited by the presence of the cyst fluid material. SHydroxytryptamine was not oxidized, but there was a moderate catalysis of the oxidation of p-phenylenediamine. However, when the aqueous solution of the redissolved lyophilized cyst fluid was heated at 100° C. for 5 minutes before being employed, comparable oxygen consumption occurred. The catalysis was therefore presumably nonenzymatic. Two hundred and fifty milligram portions of the lyophilizcd material were dissolved in 1 ml. of ion-free water and 1 ml. of a mixture of n-butanol-acetic acid-water (60: 10: 20)) and 50 lamhda samples were applied to Whatman No. 1
Volume Number
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Melanogenic
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tumors
673
filter paper strips. These were subjected to descending chromatography in n-butanol-acetic acid-water and stained as previously described.z2 The ninhydrin reagent demonstrated 4 discrete bands having R, values 0.13, 0.26, 0.46, and 0.65. The R, value of authentic 3-hydroxytyramine (dopamine) in this system was 0.47. Both the R, 0.46 material and dopamine gave identical red colors with Pauly’s reagent and identical yellow colors with Ehrlich’s reagent. However, the unknown R, 0.46 material did not reduce ammoniacal silver nitrate (Fontana’s reagent), whereas strong reduction was obtained with dopaminc. Chromatographic studies of the ascitic fluid of a patient with portal cirrhosis have also shown a material of R, 0.46, which gives similar ninhydrin and Pauly reactions but which does not reduce ammoniacal silver nitrate. Second operation (Dec. 29, 1959). The left ovarian sisted
mass, almost
approximately 7 by 7 by 6 cm. conentirely of a unilocular simple cyst 6 cm. in diameter. No neoplastic
follicular tissue was noted. Large aggregates of serosal pigment were again found (uterus, ovary, tube, and appendix), both intra- and extracellularly. The pigment-laden cells appeared to be macrophages. Biopsies of several areas of black indurated peritoneum also revealed intra- and extracellular dark brown and black pigment, which is usually associated with fibrosis. Much of this pigment was refractile and stained with Prussian blue. The pigmented peritoneal nodules were thus examples of both melanosis clearly no evidence
and hemosiderosis. of melanomatosis.
There
was
Comment The differential diagnosis between ascites and a large ovarian cyst that has risen from the pelvis can be very difficult. When the ovarian cyst is large enough to occupy the entire abdominal cavity, the differentiation from ascites may be impossible. Percussion of the abdominal wall in various positions and the presence of a fluid wave may then be of no diagnostic value. Such was the case in the patient presented here. In this patient there was a palpable 9 by 8 by 5 cm. solid firm mass in the left upper quadrant and her symptoms were referable to abdominal enlargement and gastrointestinal bleeding. This, in the absence of abnormal findings on pelvic examination, was misinterpreted as representing other than gynecologic pathology. The
Fig. 6. Typical melanin-containing throughout cyst
appearance of spindle-shaped cells found at many foci wall. (x440; reduced Y&)
pelvic examination was unfortunately performed after 9,300 ml. of coal black fluid had been removed by paracentesis. As seen later, during laparotomy, the collapsed cyst remained high in the abdomen, held by numerous adhesions, and the solid component of the tumor descended to the upper portion of the left paraumbilical region. Under the assumption that ascites was the cause of the abdominal enlargement, repeated paracenteses were performed. Most likely the wall of the ovarian cyst was perforated by the trocar needle so that at least originally the fluid aspirated was intracystic. As the wall of the cyst was ruptured, fluid was spilled into the peritoneal cavity. Once frank communication between the cavity of the cyst and the peritoneal cavity was established, ascites may then have developed. That this was the case was corroborated by the findings on laparotomy in March, 1958, when the entire abdominal contents were stained black with
674
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et al.
melanin and three possible small rents were noted in the cyst wall. In the absence of obvious medical disease associated with ascites, one should not resort to diagnostic paracentesis in the female patient. The possibility of rupture of an unsuspected ovarian cyst with spillage of its contents throughout the peritoneal cavity should would be be kept in mind. Culdocentesis preferable because often the cyst rises from the pelvis, leaving a free cul-de-sac, but laparotomy is by far the safest procedure in such instances. In our case the laparotomy findings (black nodules in the liver and hard black periaortic lymph nodes) suggested a highly malignant metastasizing neoplasm. Frozen sections of the omentum of a peritoneal nodule and of the tumor were inconclusive. Because of the length of the procedure and the patient’s status, no biopsies of the liver or lymph nodes were obtained. It was assumed at this time that biopsies of all structures would be available within a short time at the autopsy table. The whole tumor was removed and, on the basis of histologic architecture and the cytologic features of the pigment-containing cells, it was thought to be benign. A single disturbing finding was the presence of masses of pigment-laden cells “infiltrating” the adventitial tissue of the mass. These were interpreted as macrophages, although a few of these cells had a stellate shape. The question of whether these were macrophages or melanoma cells could have been resolved by the DOPA oxidase technique if frozen, unfixed tissue had been available. That this tumor was not malignant is also strongly suggested by the subsequent clinical course. After conservative surgical resection of the cystic mass, the patient recovered rapidly and remained asymptomatic. The second laparotomy, 8 months after the original operation, showed no evidence of metastasis or residual neoplastic tissue. There were no longer any nodules in the liver, the preaortic nodes had returned to normal size, and relatively little was left of the black pigmentation that originally stained all the abdominal organs. Biopsies of some black
September 1, 1962 Am. J. Obst. & Gynec.
nodules and pigmented flat areas showed dark brown to black pigment for the most part lying free in the tissue, occasionally appearing to be in the lymphatics and often concentrated about small blood vessels. Extensive laboratory studies as recorded in the case report showed normal blood cells and blood chemical determinations and no evidence of liver dysfunction or melanuria. Search for metastasis and for sites of possible primary melanotic tumor resulted in negative findings. The cause of the gastrointestinal bleeding is obscure. All gastrointestinal symptoms subsided after removal of the tumor in March, 1958, and have not recurred since. The histogenesis of this tumor is that of other teratomas. Whereas the melanin component did not appear to be associated with any organoid structures (with the possible exception of the peculiar convoluted pattern illustrated in Fig. 4)) its presence nevertheless is understandable in an ovarian teratoma. In the previously reported melanogenic tumors of the ovary, the identification of melanin was based upon the negative response to Prussian blue in 3 cases13, I41 ” and in addition by impregnation with silver and bleaching with potassium permanganate in one case.ls In 5 case+ I22 Is-l7 no statement as to the specific identification of melanin was made. In the case we are reporting, the general physical and chemical properties of the black pigment were clearly those of the melanin group, pigments generally considered to derive from tyrosine via tyrosinase catalyzed oxidations. 23 Martin and associates have recently been investigating pigments having several properties of the melanins which can be derived from hydroxylated tryptophane derivatives both enzymaticallyZ2 and nonenzymatically.24, 2’ Oxidase activity could not be demonstrated, and definite melanin precursors could not be found in this tumor. The failure to demonstrate oxidase activity may have been partially attributable to protein denaturation associated with lyophilization. If amino acid derivatives concerned with melanin formation were present in the cyst fluid, their concentrations were
Volume Number
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too low to detect under the conditions of the chromatographic experiments. The fact that 5 of the 8 reported primary malignant melanomas of the ovary were not associated with teratomatous elements is difficult to understand.14S18 The number of samples taken was not reported in any case and it is possible that the teratomatous elements were missed because of inadequate sampling. It is also possible, as one author has suggested, I8 that the melanoma completely replaced and obliterated the teratomatous elements initially present. The cytologic and histologic features of all the reported primary melanomas of the ovary were quite similar. The tumor cells were spindle-shaped, fusiform, or irregularly polyhedral with cytoplasmic granules of melanin and large round to oval vesicular nuclei. In these tumors the characteristics of malignancy were evident with anaplasia, hyperchromatism, increased nuclear cytoplasmic ratio, atypical mitosis, and invasion. In the tumor described here, the cells did not manifest these malignant features. A melanoma of the ovary can be considered primary if it is confined to the ovary and there is no evidence, and never has been, of malignant melanoma of the skin, choroid, iris, adrenal glands, or choroid plexus. Its presence within an ovarian teratoma further suggests its ovarian origin. From the cases reported in the literature, the finding of a black, solid ovarian tumor implies that one is dealing with a malignant melanoma of the ovary. The treatment is bilateral salpingo-oophorectomy and total hysterectomy. The presence of metastasis or the degree of local involvement may permit only local removal of tumor or biopsy. It is well known that melanomas which metastasize to the ovary are much more frequent than are primary melanomas of the ovary. Therefore, when an unsuspected melanotic tumor of the ovary is found, meticulous scrutiny of all possible primary sites must be carried out. This should include a careful examination of the skin with removal and pathologic examination of pigmented or otherwise suspicious nevi, ophthal-
Melanogenic
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moscopic consultation, complete neurological examination, urinalysis for melanin, and adrenal function tests, even if palpation of the adrenal glands reveals no abnormalities. If an extrapelvic primary melanoma is found after this careful search, the surgery performed for the ovarian tumor must be considered palliative. Even though also palliative, the use of chemotherapeutic agents such as colchicine derivatives may then be considered. If the final diagnosis is primary malignant melanoma of the ovary, postoperative x-ray therapy is recommended. If the black ovarian tumor is obviously cystic and no metastasis is found, the possibility of benignity must be considered. Depending on the age of the patient and on her condition, removal of the tumor (unilateral oophorocystectomy) with wedge biopsy of the opposite ovary is the treatment of choice. In the event that pathologic examination reveals malignant or suspicious changes, the management should then be similar to that described for the solid tumor. A second laparotomy with removal of the whole uterus, both tubes, and the remaining ovary is advised if there is no evidence of malignant melanoma elsewhere in the body. A frozen section should be obtained any time one suspects malignancy, but it is only conclusive if it shows definite malignancy. The findings of black India ink-like, guaiac-negative fluid on paracentesis should strongly suggest the diagnosis of melanogenic ovarian tumor, and preoperative evaluation of the patient along the lines previously described should be carried out. The ovarian teratoma found in this patient developed in the right ovary, and it was clinically benign. As of April 1, 1962, 4 years and one week after the first laparotomy, the patient is well and asymptomatic without evidence of recurrence.
Summary 1. All previously reported cases of primary melanoma of the ovary are reviewed. 2. A cystic ovarian teratoma is reported in which a pigmented component produced the
676
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predominant clinical and pathologic findings. In contrast to all other such neoplasms rethis lesion is ported in the literature, apparently benign. 3. The physical, chemical, and histochemical properties of the pigment were those of the melanins. However, chromatographic and manometric studies of the lyophilized cyst fluid failed to reveal definite melanin pre-
cursors or oxidase activity under mental conditions employed.
the experi-
WC an ~mtcful 10 Drs. I. Schuldberg, J. Hennctt, P. Steiner, Ii. Willis, F. Stewart, and J. D. Woodruff for their valuable comments on the microscopic matrrial. We wish also to espress our thanks to Dr. R. Vackro for his translations of thr Grrman literature and to Dr. R. R. Murphy for his aid in the study of this patient.
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5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Lynch, F. W., and Maxwell, A. F.: Pelvic Neoplasms. Gynecological and Obstetrical Monographs, New York, 1922, D. Appleton & company, p. 373. Eden. T. W.. and Lockver. C.: Thr New Systek of Gyhecology, NLw ?ork, 1917, The Macmillan Company, p. 828. Frank, R. T.: Gynecological and Obstetrical Pathology, New York, 1922, D. .4ppleton & Company, p. 414. Rubin, I. C., and Novak, J,: Integrated Gynecology, New York, 1956, McGraw Hill Book Company, Inc., vol. 2, p. 67. Miller, J. R.: New England J. Med. 199: 830, 1928. Nowak, I.: iirch. Gynsk. 112: 183, 1920. Dawson, H. G. W.: Brit. M. J. 2: 757, 1922. Basso, G. L.: Ginecologica Firenze 5: 257, 1908. Bab. H.: Arch. Gynlk. 79: 158, 1906. Ganse. R.: Zentralbl. GvnHk. 77: 1146. 1955. Lorrain. M.: Presse med. 41: 328, 1965. Amann, J. A.: Centralbl. Gynzk. 27: 213, 874, 1903. Martial-Rojas, R. A., and Ramirrz de Arellane, G. A.: Cancer 9: 523, 1956. Andrews, R.: Tr. Obst. Sot. Lond. 43: 228. 1901.
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21. 22. 23.
24. 25.
Winternitz, M. C.: Johns Hopkins Hosp. Bull. 20: 314, 1909. Soubeyran and Rives: Arch. g&n. chir. 7: 1098, 1911. Otken, L. B.: Am. J. Surg. 55: 160, 1942. Jernstrom, P., and MacMuffy, H.: Am. J. Clin. Path. 32: 557, 1959. Willis, R. A.: Tcratomas, Atlas of Tumor Pathology, Washington, D. C.. 1951, sect. III, fast. 9, Armed Forces Institute of Patholo~gy. Peterson, W. F., Prevost, E. C., Edmunds, F. T., Huntley, J. M., Jr., and Morris, F. K.: AM. 1. OBST. & GYNEC. 70: 368. 1955. Simard, I,. C.: Cancer 10: 215, ‘1957. Martin, G. M., Benditt, E. P., and Eriksen, N.: Arch. Biochem. 90: 208, 1960. Pearse, A. G. E.: Histochemistry, ed. 2, London, 1960, J. & A. Churchill, Ltd., p. 632. Eriksen, N., Martin, G. M., and Benditt, E. P.: J. Biol. Chem. 235: 1662, 1960. Martin, G. M., Benditt, E. P., and Eriksen, N.: Nature 186: 884, 1960. university of Washington Seattle 5, Washington (Dr. de Alvarez)
F.
GEORGE
AFONSO, M.
FRANK
Seattle,
MARTIN,
S. NISCO,
RUSSELL
R.
M.D. M.D. M.D.”
DE ALVAREZ,
M.D.
Washington
MELANIN-PRODUCING ovarian tumors can be primary or secondary. Secondary melanogenic ovarian tumors are usually metastatic from malignant melanomas of the skin or choroid.l-10 Secondary melanomas of the ovary are not uncommon and at least 49 cases have been reported.l An additional 9 cases were described in which the ovarian metastasis assumed the form of a large homogenous tumor so that the preoperative diagnosis of primary ovarian neoplasm was made.5-10 Primary malignant melanomas of the ovary are rare. Review of the literature from 1900 through 1960 reveals only 8 cases in which the malignant melanoma may have been primary in the ovary. Three of these developed in dermoid cysts,11-13 and in the other 5 the melanoma did not seem to be associated with any teratomatous elements.l*-I8 When the melanoma was associated with the dermoid cysts, it appeared as a solid, nodular, black area in the cyst wall. The other tumors were mostly solid with lobulated external surface and of elastic or firm consistency. The cut surfaces were uniformly black or showed
islands of black tissue segregated by firm gray-white septa. The color of the external surfaces was uniformly or partly black, dark blue, or grayish brown. Two of these tumors were bilateraY7 l7 and 6 were confined to one ovary.11-15s I8 These tumors were freely movable except for occasional adhesions to the surrounding structures. The symptoms associated with these tumors were similar to those of other nonfunctioning ovarian tumors, and in one caseI the first symptoms were referable to a metastasis. Of these neoplasms only one was associated with pregnancy and was removed during the fourth month of gestation.14 The ages of the patients varied from 26 to 77 years. Malignant melanomas of the ovary are expected to be highly malignant, but no valid conclusions can be drawn in this regard from the cases recorded in the literature because both treatment and follow-up were inadequate. The treatment consisted of simple removal of the tumors in 2 cases,“) lfi unilateral salpingo-oophorectomy in one case,13 and in another bilateral salpingo-oophorectomy and subtotal hysterectomy.17 No treatment was mentioned in two reports,ll, l2 and in one report it was stated that no treatment was possible.15 In the last reported caseI the patient had had a subtotal hysterectomy and, when the ovarian tumor was found, bilateral salpingo-oophorectomy and omentopexy were performed, followed by postoperative x-ray irradiation. There was no follow-up in 3 cases.ll* 13, I6 Three patients were well, respectively, 3, 4, and 30 months after ther-
From the Department
of Obstetrics and Gynecology and the Department of Pathology, University of Washington School of Medicine, and the King County Hospital.
Supported in part by a training grant (CLT-7102) from the Cancer Institute, United States Public Health Service, and by a grant from the University of Washington Initiative 171 Funds for Research in Biology and Medicine. *National
Cancer
Institute
Trainee.
667
668
Afonso
apy.14.
17,
September 1, 1962 Am. J. Obst. & Gynec.
et al.
IS Of 2 patients known to have died, one survived 18 months after simple removal of the tumor,l? and the other was not treated and died 11 months after the onset of symptoms.15 The mode of spread of malignant melanoma of the ovary as judged by the cases reported is through the lymphatics (isolated right inguinal node metastasis in one caseI”) , blood stream (generalized osseous metastasis and liver metastasis in one patient,]’ isolated brain metastasis in another’“) and by continuity, with generalized abdominal melanomatosis or localized omental metastasis.“, Ifi Ovarian teratomas often include minor components which produce or contain melanin, representing adult structures that normally contain this pigment.1”-21 Considering that in ovarian teratomas the growth and development of some tissue is much greater than in that of others,l”-Z1 one can expect to find tumors in which the melanin-producing elements predominate. All such neoplasms previously
reported
lesion which benign.
we
have
been
report
here
malignant.
The
is apparently
Case report Present illness. Miss single, white nulligravida,
M. T., an 18-year-old,
King
March
County
Hospital
was
admitted
to
the
2, 1958, hecausc
of abdominal swelling of 9 months’ duration. She had heen well until June, 1957, when she noted left upper qtiadrant pain and hematemesis. Gastrointestinal findings were negative, and she received multiple transfusions. Ahdominal enlargement was noted at this time. She f<,lt well until August, 1957, when the hematemesis recurred and several blood transfusions wcrc required. Repeated gastrointestinal srrics showed no abnormalities. In October, 1957, the abdomen was found to he markedly distended, and on paracentcsis a black, watery, guaiac nrgative fluid was obtained. This fluid reaccumulated requiring repeated paraccntcses. The patient continued to lose weight and felt well except for the discomfort of recurrent abdominal enlargement. She had had a normal menarche at the age of 11, and the menses had been normal until July, 1957, when the cycles became irrc,gular. In October, 1957. she developed amenorrhea.
Past history and family history. Past history family history were both noncontributory. Physical examination. On admittance the patient appeared thin, pale, and chronically ill. The vital signs \vere normal. General physical rxamination showed only the following positive findings: there were marked abdominal distention and skin wounds from previous paraccnteses, the entire ahdomcn was flat to percussion and a fluid wave was present, and a slightly tender, 9 by 6
and
by 5 cm. firm, fairly smooth, partially
movable
mass filled the left upper quadrant. Laboratory and x-ray examination. On admittance thr, venereal disease laboratory tests wcrc nonrcactivc, the hcmatocrit reading was 23 per cent, and the white hlood cell count was 5,000 per cubic millimeter with a normal differential count. Srrum crcatinine, electrolytes, alkaline phosphatasc, bilirubin, serum total protein and protrin fractions wcrc normal. Clotting time, clot retraction and stability, and prothrombin timr: wcrf’ normal. The sulfobromophthalein and thymol turbidity trsts were normal and the cephalin flocculation test was 3-plus. Catheterized urine analysis and stool guaiac wcrc ncgativr. Bone marrow examination showed no abnormaliticzs except for depletion of iron stores. A chest film showcxd patchy atclectasis at the right has?, and a Hat plate of the abdomen showed ohlitcratlon of soft tissue sh adows. Uwcr gastrointestinal series revealed minimal lower esophageal varices and upward displacement of the stomach. An intravenous pyelogram drmonstrated right hydroureter and hydronephrosis. Hospital course. After admission a paracentesis was performed, yielding 9,300 ml. of India inklike fluid of specific Rravity 1.020, containing 1 white blood cell per 1 c.c., 204 mg. of protein per 100 c.c., and 3.5 units of amylasc activity per 100 c.c. After rc,moval of this fluid thrs upprr quadrant mass descended to the lrft parautnbilical r+ @on. A pelvic examination done at this time showed no abnormalitic~s. Rpd ccl1 and plasma volume< r&ctcd marked depletion of the red ccl1 mass, and thr patient was transfused with 5 units of packed ~11s. A sigmoidoscopic examination was negative, and csophagoscopy showed a hiatal hernia. Following a second paraccntesis and the removal of 2,250 nil. of black fluid, diatrizoatc methylglucamine (Rcnografin) was injected, and a flat plate of the abdomen showed the opaque material outlining a 12 by 24 cm. cystic structurcb lying anteriorly tn thr spinrx.
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84 5
Gynecologic consultation was sought. On March 19, 1958, an exploratory laparotomy was performed. All structures within the peritoneal cavity were variably covered and stained by a coal black, India ink-like fluid which made differentiation of the various structures extremely difficult. The spleen and the kidneys were normal to palpation. Filling the abdominal cavity was a 24 by 17.5 by 7.5 cm. cystic mass of grayish color, streaked with black pigment and of smooth contour except for a black 9 by 5 by 5 cm. firm component which occupied its left upper pole. During the dissection it became apparent that the tumor arose from and replaced the right ovary. The stomach and small bowel were displaced and compressed into the upper abdomen, and the colon partially circumscribed the tumor at its periphery. The tumor was adherent to the anterior abdominal wall and to the pelvic peritoneum. A few thin adhesions were present between the tumor and the liver. The liver was slightly enlarged and had an irregular hard nodular surface. Iliac and periaortic lymph nodes were enlarged, hard, and black. The uterine fundus was normal. Right salpingo-oophorectomy was performed. Frozen sections of omental and peritoneal nodules and of the tumor showed only heavily pigmented fibroadipose tissue and suggested that the ovarian tumor was either a pseudomucinous cystadenoma or a teratoma. Because of the apparent dissemination of the disease, no further surgical intervention was undertaken. The patient’s postoperative course was completely uneventful and she was discharged from the hospital on the tenth postoperative day to return to the care of her private physician. Subsequent course. Following discharge she felt well and resumed a normal menstrual pattern within 2 months. She was readmitted for evaluation on Sept. 20, 1959. Complete physical examination revealed as the only abnormality a 10 by 7 by 6 cm. cystic, nontender, movable mass in the left adnexal area. All the laboratory tests previously reported were repeated and found to be normal. A urine test for melanin was negative. The glucose tolerance test, protein bound iodine, and blood urea nitrogen were normal. Chest, skull roentgenograms, intravenous pyelograms, and upper gastrointestinal series showed no abnormalities. A Papanicolaou smear showed normal cells. Because the left ovarian cyst persisted and had enlarged slightly, an exploratory Iaparotomy was performed Dec. 29,
Melanogenic
ovarian
tumors
669
1959. When the abdominal cavity was opened, multiple patches of black pigment, up to an area of 4 by 5 cm. each, stained both the parietal and visceral peritoneum. Black staining of areas of the mesentery and appendiceal serosa were also noted. The pelvic peritoneum was aimost entirely black in color, and the serosa of all pelvic viscera was streaked with black pigment. The uterus appeared normal except for the coloration of its serosa, and the right tube and ovary were absent. The left ovary was replaced by a 6 by 10 by 6 cm. cystic tumor bound to the lateral pelvic wall by thin adhesions stained with black pigtnent in its outer surface. Both kidneys, adrenal glands, spleen, and liver were normal to palpation. There wrre no other abnormalities found in the abdominal cavity, and the periaortic lymph nodes appeared normal. The serosa of the liver was stained with black pigment in some areas but no nodules were now palpable. A left salpingo-oophorectomy, total hysterectomy, and appendectomy were performed, and several biopsies were taken from the parietal and pelvic peritoneum. The patient tolerated the operation well and recovered rapidly. When discharged she was advised to continue stilbesterol, 1 mg. daily, and has remained asymptomatic and entirely well qince. Pathologic studies. First
operation
(March
19, 1958).
The cystic, fluctuant right ovarian mass weighed 1,925 grams and was 24 by 17.5 by 7.5 cm. in over-all greatest dimensions (Fig. 1). Most of the surface was relatively smooth, glistening, and pink, except for tortuous streaks of black pigment, some of which appeared to outline blood vessels. Several solid, irregularlyovoid adherent nodules of black tissue were up to 2 cm. in greatest dimension. Adhering to the surface of the large cystic mass was a tubular structure resembling an oviduct; it was 10 cm. in length and averaged 0.6 cm. in diameter. An irregularly ovoid body of firm black tissue covered a portion of the main cystic mass. It was said to have occupied the left upper pole of the mass in situ. On cut section, it proved to be a discrete subsidiary mass, 9.5 by 5 by 5.2 cm., consisting of a central cavity 4.5 by 3.5 by 4.9 cm., surrounded by a discrete wall of firm black tissue, 0.6 to 1.3 cm. in thickness (Fig. 2). Except for a few streaks of gray, this wall was homogeneously black. The principal cystic portion of the mass contained more than a liter of thin, turbid, black, GROSS
EXAMINATION.
670
Afonso et al.
Fig. 1. Gross appearance of tumor: external surface.
Fig. 2. Gross appearance of tumor: cut section, showing lining of large cyst and of subsidiary black mass.
Scptcmber 1, 1962 Am. J. Obst. & Gynec.
odorless fluid. The gray-tan cyst lining was relatively smooth, but finely “pebbled” and, in its collapsed state, grossly convoluted. A few scattered fine and coarse black markings and occasional cystic excrescences were present, the latter ranging up to 1.5 cm. in greatest dimension. The wall of the large cyst ranged from 1 to 10 mm. in thickness. MICROSCOPIC EXAMINATION. Forty-one samples from the formalin-fixed tissues were embedded in 27 paraffin blocks and stained with hematoxylin and eosin. All samples from the large cyst showed a lining of glandular columnar epithelium resembling gastrointestinal (Fig. 3), usually mucosa, particuIarly the pyloric region of the stomach. Many glands contained large eosinophilic cells resembling gastric parietal cells (Fig. 4). Some observers noted a resemblance of portions of this mucosal lining to cervical cpithelium. In several foci there was acute ulceration of the mucosa, with fibrinous exudation, hemorrhage, and young granulation tissue. The bulk of the wall of the cyst consisted of scanty cellular connective tissue, varying from loose, palely cosinophilic tissue with stellate fibroblasts to dense, compact hyaline material. Parallel strands and bundles of smooth muscles were found. Vascular channels were scattered throughout these tissues. Widely separated samples showed remnants of ovarian tissue in the form of intramural follicular cysts. A single maturing ovarian follicle was noted. Typical ovarian stroma was not found. Numerous isolated, discrete aggregates of melanin-containing tissue were noted which were usually ovoid in outline and varied from microscopic foci found just beneath the mucosal lining to the grossly noted black nodules projecting from the surface of the large cyst (Fig. 5). L4 few were in the midportion of the cyst wall. Invariably the dark brown to black, coarsely granular pigment was associated with dense sclerotic connective tissue, usually 3 palely cosinophilic tissue with scattered, rare, compact, deeply basophilic spindle-shaped nuclei. The pigment generally appeared to be depositrd in the stroma but in all nodules could also he found filling the cytoplasm of elongated spindle-shaped cells varying from about 20 to 40 p in length (Fig. 6). They were usually arranged in parallel layers and bundles. Their ovoid centrally placed nuclei were sharply outlined by the pigment. They contained little chromatin and typically possessed single, discrete, paracentric nucleoli. The nuclei were on the average
Volume Number
84 5
Melanogenic
about 5 p in length. A minority of the pigmentcontaining cells had a rounded configuration and a disproportionately abundant cytoplasm. These cells were suggestive of macrophages. Perivascular aggregates of pigment were found throughout most of the adventitial tissues of the cyst. The cells containing this pigment were more typically of the macrophage configuration, but definite spindle forms could also be found. Abundant serosal perivascular intracellular deposits of brown and black pigment were also found in sections of an otherwise normal-appearing Fallopian tube. Scanty depositions of pigment were also noted in the lamina propria of the mucosal folds. The large, black, centrally cystic subsidiary mass was histologically quite similar to the smaller nodules found on and within the main cyst wall. The accumulation of melanin pigment was much more spectacular, however, there being large acellular pools of black pigment in what was apparently degenerated tumor tissue. Accumulations of unstained elongated spaces in these regions were suggestive of “cholesterol clefts.” A single, multinucleated foreign body giant cell was found in these tissues. It contained pigment and clefts. Fibrin strands adhered to the lining of the central cavitation. The black mass was densely adherent to th,: wall of the main cyst
Fig. 3. Portion (x100; reduced
of cyst wall I/*.)
ovarian
tumors
671
but was sharply delineated from this wall, usually by numerous flattened, elongated, apparently discontinuous cystic spaces which were lined by a single layer of small flat to cuboidal epithelial cells. A biopsy of an omental “node” contained superficial aggregates of large pigment-laden cells which seemed clearly to be macrophages. A biopsy of a hard anterior-wall peritoneal nodule consisted of sclerotic melanotic tissue quite similar to that found in the main mass. Both spindle-shaped and rounded cell types were included. HISTOCHEMICAL STUDIES. Prussian blue stains for iron were consistently negative, except for a very rare intracellular deposit of granular blue pigment. It was difficult to interpret argentaffin stains, since virtually all the pigment was already dark brown to black. In areas where the pigment was less dense, however, ammoniacal silver nitrate appeared to be reduced by the pigment, with the deposition of black metallic silver. The use of a strong oxidizing agent (10 per cent fresh H,O,) resulted in a gradual bleaching of pigment from black to brown to yellow to colorless in a period of about 24 hours. Unfortunately, oxidase activity of the cells could not be evaluated because of relatively prolonged formalin fixing.
lined by simple columnar
mucosecretory
epithelium.
672
Afonso
Fig. 4. Gastric wall, including (~440: reduced
et al.
glands large 9:. i
from pale
lining of portion globular parietal
of cyst cells.
CHEMICAL STUDIES. An aliquot of the coal black fluid from the main cyst was centrifuged and a large quantity of heavy, black precipitate was obtained. This pigment was highly insoluble in a variety of organic and aqueous solvents, including strong acids. It was slowly dissolved by 5 N NaOH. Ten per cent H?O, slowly bleached the pigment to a colorless product. When the pigment was examined under ultraviolet light, a dull green fluorescence was observed. Lyophilization of 420 ml. of this fluid resulted in 19.5 grams of pale gray powder. Two hundred and fifty milligrams per milliliter of aqueous solutions of this material were employed in Warburg manometric. studies designed to demonstrate oxidase activity. The main compartments of the flasks contained 1.6 ml. of the redissolved
lyophilized cyst fluid and 0.6 ml. of 0.2 M phosphate buffer. The side arms contained 0,6 ml. of substrate. The center walls contained 0.2 ml. of 10 per cent KOH. The following substrates were employed : ~-3, 4-dihydroxyphenylalanine I.-tyrosine, 5-hydroxytryptamine crca(DOPA), tine sulfate, and p-phenylenediamine. The final
Fig. 5. Convoluted, found in a solid large cyst. (x35:
organoid deposition of melanin fibrotic nodule on surface of the reduced ;C,.)
concentrations of substrate were 6 mM. except for r.-tyrosine, in which case saturated solutions were employed. The ph was 7.4 in the case of the first two substrates and 6.2 in the case of the last two substrates. Appropriate control flasks were prepared and the rate of oxygen consumption was observed at :3’i” C. for a period of 3 hours after a 15 minute equilibration period. No tyrosinase or DOPA oxidase activity could be detrctcd. In fact, the spontaneous oxidation of DOPA was markedly inhibited by the presence of the cyst fluid material. SHydroxytryptamine was not oxidized, but there was a moderate catalysis of the oxidation of p-phenylenediamine. However, when the aqueous solution of the redissolved lyophilized cyst fluid was heated at 100° C. for 5 minutes before being employed, comparable oxygen consumption occurred. The catalysis was therefore presumably nonenzymatic. Two hundred and fifty milligram portions of the lyophilizcd material were dissolved in 1 ml. of ion-free water and 1 ml. of a mixture of n-butanol-acetic acid-water (60: 10: 20)) and 50 lamhda samples were applied to Whatman No. 1
Volume Number
81 5
Melanogenic
ovarian
tumors
673
filter paper strips. These were subjected to descending chromatography in n-butanol-acetic acid-water and stained as previously described.z2 The ninhydrin reagent demonstrated 4 discrete bands having R, values 0.13, 0.26, 0.46, and 0.65. The R, value of authentic 3-hydroxytyramine (dopamine) in this system was 0.47. Both the R, 0.46 material and dopamine gave identical red colors with Pauly’s reagent and identical yellow colors with Ehrlich’s reagent. However, the unknown R, 0.46 material did not reduce ammoniacal silver nitrate (Fontana’s reagent), whereas strong reduction was obtained with dopaminc. Chromatographic studies of the ascitic fluid of a patient with portal cirrhosis have also shown a material of R, 0.46, which gives similar ninhydrin and Pauly reactions but which does not reduce ammoniacal silver nitrate. Second operation (Dec. 29, 1959). The left ovarian sisted
mass, almost
approximately 7 by 7 by 6 cm. conentirely of a unilocular simple cyst 6 cm. in diameter. No neoplastic
follicular tissue was noted. Large aggregates of serosal pigment were again found (uterus, ovary, tube, and appendix), both intra- and extracellularly. The pigment-laden cells appeared to be macrophages. Biopsies of several areas of black indurated peritoneum also revealed intra- and extracellular dark brown and black pigment, which is usually associated with fibrosis. Much of this pigment was refractile and stained with Prussian blue. The pigmented peritoneal nodules were thus examples of both melanosis clearly no evidence
and hemosiderosis. of melanomatosis.
There
was
Comment The differential diagnosis between ascites and a large ovarian cyst that has risen from the pelvis can be very difficult. When the ovarian cyst is large enough to occupy the entire abdominal cavity, the differentiation from ascites may be impossible. Percussion of the abdominal wall in various positions and the presence of a fluid wave may then be of no diagnostic value. Such was the case in the patient presented here. In this patient there was a palpable 9 by 8 by 5 cm. solid firm mass in the left upper quadrant and her symptoms were referable to abdominal enlargement and gastrointestinal bleeding. This, in the absence of abnormal findings on pelvic examination, was misinterpreted as representing other than gynecologic pathology. The
Fig. 6. Typical melanin-containing throughout cyst
appearance of spindle-shaped cells found at many foci wall. (x440; reduced Y&)
pelvic examination was unfortunately performed after 9,300 ml. of coal black fluid had been removed by paracentesis. As seen later, during laparotomy, the collapsed cyst remained high in the abdomen, held by numerous adhesions, and the solid component of the tumor descended to the upper portion of the left paraumbilical region. Under the assumption that ascites was the cause of the abdominal enlargement, repeated paracenteses were performed. Most likely the wall of the ovarian cyst was perforated by the trocar needle so that at least originally the fluid aspirated was intracystic. As the wall of the cyst was ruptured, fluid was spilled into the peritoneal cavity. Once frank communication between the cavity of the cyst and the peritoneal cavity was established, ascites may then have developed. That this was the case was corroborated by the findings on laparotomy in March, 1958, when the entire abdominal contents were stained black with
674
Afonso
et al.
melanin and three possible small rents were noted in the cyst wall. In the absence of obvious medical disease associated with ascites, one should not resort to diagnostic paracentesis in the female patient. The possibility of rupture of an unsuspected ovarian cyst with spillage of its contents throughout the peritoneal cavity should would be be kept in mind. Culdocentesis preferable because often the cyst rises from the pelvis, leaving a free cul-de-sac, but laparotomy is by far the safest procedure in such instances. In our case the laparotomy findings (black nodules in the liver and hard black periaortic lymph nodes) suggested a highly malignant metastasizing neoplasm. Frozen sections of the omentum of a peritoneal nodule and of the tumor were inconclusive. Because of the length of the procedure and the patient’s status, no biopsies of the liver or lymph nodes were obtained. It was assumed at this time that biopsies of all structures would be available within a short time at the autopsy table. The whole tumor was removed and, on the basis of histologic architecture and the cytologic features of the pigment-containing cells, it was thought to be benign. A single disturbing finding was the presence of masses of pigment-laden cells “infiltrating” the adventitial tissue of the mass. These were interpreted as macrophages, although a few of these cells had a stellate shape. The question of whether these were macrophages or melanoma cells could have been resolved by the DOPA oxidase technique if frozen, unfixed tissue had been available. That this tumor was not malignant is also strongly suggested by the subsequent clinical course. After conservative surgical resection of the cystic mass, the patient recovered rapidly and remained asymptomatic. The second laparotomy, 8 months after the original operation, showed no evidence of metastasis or residual neoplastic tissue. There were no longer any nodules in the liver, the preaortic nodes had returned to normal size, and relatively little was left of the black pigmentation that originally stained all the abdominal organs. Biopsies of some black
September 1, 1962 Am. J. Obst. & Gynec.
nodules and pigmented flat areas showed dark brown to black pigment for the most part lying free in the tissue, occasionally appearing to be in the lymphatics and often concentrated about small blood vessels. Extensive laboratory studies as recorded in the case report showed normal blood cells and blood chemical determinations and no evidence of liver dysfunction or melanuria. Search for metastasis and for sites of possible primary melanotic tumor resulted in negative findings. The cause of the gastrointestinal bleeding is obscure. All gastrointestinal symptoms subsided after removal of the tumor in March, 1958, and have not recurred since. The histogenesis of this tumor is that of other teratomas. Whereas the melanin component did not appear to be associated with any organoid structures (with the possible exception of the peculiar convoluted pattern illustrated in Fig. 4)) its presence nevertheless is understandable in an ovarian teratoma. In the previously reported melanogenic tumors of the ovary, the identification of melanin was based upon the negative response to Prussian blue in 3 cases13, I41 ” and in addition by impregnation with silver and bleaching with potassium permanganate in one case.ls In 5 case+ I22 Is-l7 no statement as to the specific identification of melanin was made. In the case we are reporting, the general physical and chemical properties of the black pigment were clearly those of the melanin group, pigments generally considered to derive from tyrosine via tyrosinase catalyzed oxidations. 23 Martin and associates have recently been investigating pigments having several properties of the melanins which can be derived from hydroxylated tryptophane derivatives both enzymaticallyZ2 and nonenzymatically.24, 2’ Oxidase activity could not be demonstrated, and definite melanin precursors could not be found in this tumor. The failure to demonstrate oxidase activity may have been partially attributable to protein denaturation associated with lyophilization. If amino acid derivatives concerned with melanin formation were present in the cyst fluid, their concentrations were
Volume Number
84 5
too low to detect under the conditions of the chromatographic experiments. The fact that 5 of the 8 reported primary malignant melanomas of the ovary were not associated with teratomatous elements is difficult to understand.14S18 The number of samples taken was not reported in any case and it is possible that the teratomatous elements were missed because of inadequate sampling. It is also possible, as one author has suggested, I8 that the melanoma completely replaced and obliterated the teratomatous elements initially present. The cytologic and histologic features of all the reported primary melanomas of the ovary were quite similar. The tumor cells were spindle-shaped, fusiform, or irregularly polyhedral with cytoplasmic granules of melanin and large round to oval vesicular nuclei. In these tumors the characteristics of malignancy were evident with anaplasia, hyperchromatism, increased nuclear cytoplasmic ratio, atypical mitosis, and invasion. In the tumor described here, the cells did not manifest these malignant features. A melanoma of the ovary can be considered primary if it is confined to the ovary and there is no evidence, and never has been, of malignant melanoma of the skin, choroid, iris, adrenal glands, or choroid plexus. Its presence within an ovarian teratoma further suggests its ovarian origin. From the cases reported in the literature, the finding of a black, solid ovarian tumor implies that one is dealing with a malignant melanoma of the ovary. The treatment is bilateral salpingo-oophorectomy and total hysterectomy. The presence of metastasis or the degree of local involvement may permit only local removal of tumor or biopsy. It is well known that melanomas which metastasize to the ovary are much more frequent than are primary melanomas of the ovary. Therefore, when an unsuspected melanotic tumor of the ovary is found, meticulous scrutiny of all possible primary sites must be carried out. This should include a careful examination of the skin with removal and pathologic examination of pigmented or otherwise suspicious nevi, ophthal-
Melanogenic
ovarian
tumors
675
moscopic consultation, complete neurological examination, urinalysis for melanin, and adrenal function tests, even if palpation of the adrenal glands reveals no abnormalities. If an extrapelvic primary melanoma is found after this careful search, the surgery performed for the ovarian tumor must be considered palliative. Even though also palliative, the use of chemotherapeutic agents such as colchicine derivatives may then be considered. If the final diagnosis is primary malignant melanoma of the ovary, postoperative x-ray therapy is recommended. If the black ovarian tumor is obviously cystic and no metastasis is found, the possibility of benignity must be considered. Depending on the age of the patient and on her condition, removal of the tumor (unilateral oophorocystectomy) with wedge biopsy of the opposite ovary is the treatment of choice. In the event that pathologic examination reveals malignant or suspicious changes, the management should then be similar to that described for the solid tumor. A second laparotomy with removal of the whole uterus, both tubes, and the remaining ovary is advised if there is no evidence of malignant melanoma elsewhere in the body. A frozen section should be obtained any time one suspects malignancy, but it is only conclusive if it shows definite malignancy. The findings of black India ink-like, guaiac-negative fluid on paracentesis should strongly suggest the diagnosis of melanogenic ovarian tumor, and preoperative evaluation of the patient along the lines previously described should be carried out. The ovarian teratoma found in this patient developed in the right ovary, and it was clinically benign. As of April 1, 1962, 4 years and one week after the first laparotomy, the patient is well and asymptomatic without evidence of recurrence.
Summary 1. All previously reported cases of primary melanoma of the ovary are reviewed. 2. A cystic ovarian teratoma is reported in which a pigmented component produced the
676
Afonso
et al.
predominant clinical and pathologic findings. In contrast to all other such neoplasms rethis lesion is ported in the literature, apparently benign. 3. The physical, chemical, and histochemical properties of the pigment were those of the melanins. However, chromatographic and manometric studies of the lyophilized cyst fluid failed to reveal definite melanin pre-
cursors or oxidase activity under mental conditions employed.
the experi-
WC an ~mtcful 10 Drs. I. Schuldberg, J. Hennctt, P. Steiner, Ii. Willis, F. Stewart, and J. D. Woodruff for their valuable comments on the microscopic matrrial. We wish also to espress our thanks to Dr. R. Vackro for his translations of thr Grrman literature and to Dr. R. R. Murphy for his aid in the study of this patient.
REFERENCES
1.
2.
3.
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