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Melanoma of the vulva
5]2
AMERICAN JOURNAL OF OBSTETRICS AND GYNECO]~OGY
to the site of torsion. There was no evidence of inflammation. The opposite adnexa were normal. This case may be therefore viewed as one of segmental torsion and necrosis of a previously normal tube occurring in a young virgin. ]530 PRESIDENT STREET
MELANOMA
OF
TtIE
V U L V A ~:~
R . CHARLES NUCCI, M . D . , F . A . C . S . , PITTSBURGH, PA.
(From the 1)epart,ment of Gynv(~ology of the Elizabeth ~gteel Magec Hospital and the University o1 Pittsbt~r.qh.) UPANG the past year it has been the writer's goo(] fl)rtune to chance upon a very infrequent ~ype of malignancy of the vulva, namely, malignant melanoma. Mrs. M. I., a 76-year-old white woman, was seen in the Magee Dispensary complaining of "~lumps" in the vulva and both inguinal legions. The patient stated that she h~t always had a small mole on l]Jc righ~ labium majus. In October. 1932 she first noticed black " l u m p s " on the right vulva, which were painless. Four months later they began to bleed and were considerably larger. On Feb. 13. 1936. " l u m p s " were observed in the right groin, following three operations a month previously under local anesthesia. Six weeks before admission the patient felt additional " ' l u m p s " in the left groin. At this time she had had a serosanguineous vaginal discharge for about eighteen months. The " l u m p s ~' had been painful for about two years and were becoming progressively larger. She had lost only a slight amount of weight. Associated symptoms included headache, blurring of vision, tinnitus, and episodes of abdominal discomfort following ingestion of fried foods. The menstrual history was normal and the menopause occurred at the age of fifty. She had had two normal ~ull-term pregnancies. The past medical history included ~yphoid, measles, influenza, and diphtheria. The famil$ history was negative for malignancy. There was marked wrinkling of the skin. The vessels were hard, tortuous, and sclerosed. She had complete dentures. The tonsils were enlarged. The heart was not enlarged but a few premature bea~s were noted. There was slight 1)retibial edema. The vulvar lesion (F~g. 1) consisted of a large somewhat nodular mass. irregularly the size of a ~angerine, occupying the entire right labium minor and of a purplish color. The lower surface of the mass presented some ulceration and extended out to the clitoris, prepuce, upper part of left labium minor, and had infiltrated through so that there were several pigmen?~ed spots, of various sizes, on the outer surface of the right labium major. There were large firm masses in both inguinal regions. Laboratory findings. The urine was negative except for a few white blood corpuscles. I t was negative for melanin. Blood count: 1~. B. C., 3,690,000; W. B. C., 5,550; polymorphonuclears, 56 per cen¢; lymphocytes, 43 per cent. The blood sugar was 120 mg. Nonprotein nitrogen was 24.3 mg. Kahn was negative. Sedimentation time was 20 rain. Course ~ hospital. On Dec. 21. ]936, under gas-ether anesthesia a biopsy was taken and four radium needles, containing 1 2 ~ rag. of radium each, were inserted directly into the vulvar mass. for a period of forty-eight hours (2,400 rag. hr. of radiation). Pathologiv tCvport l~'rom Biopsy. The tumor (Fig. 2) was composed o f a itleoo morphic type of ceil, varying from spindle cell type to a large epithelial type. The cells varied in their melanin content, some o f them being melanin free, aad othera
D
*Read at a meeting of the Pittsburgh Obstetrical and Gynecological Society, February 7, 1938.
~ucc~:
MFZ~ANOMA OF VULVA
513
so packed with pigment that the cell outline was lost. There were ureas of necrosis, but for the most part the tumor was quite cellular. With the Wilder silver stain, some of the spindle-shaped cells had fibrils, while other cells were devoid of fibrils. The fibril-free cells predominated. The distribution of the pigment varied in different cells, some of the cells being so packed with pigment as to render obscure the cell 'outlines, while other cells were devoid of pigment. Diagnosis : Melanoma of the vulva.
Fig. 1.
Fig. 2. Following radiation, the muss seemed to shrink to about two-thirds of its former size and was the seat of a profuse seropurulent exudate, with the patient experiencing considerable discomfort in this area. On Jan. 17, 1937, under nitrous oxide anesthesia, radium needles were again inserted, this time around the periphery of the tumor and allowed to remain in situ for forty-eight hours (2400 mg. hr. of radiation). Symptoms continued practically the same, the patient losing ground very rapidly. On Feb. 10, 1937, about seven weeks after the initial radiation, due to the extreme discomfort of the lesion to the patient, it was decided to excise as
514
AMERICAN"JOURNAL OF OBSTETRICS AND GYNECOI.A)GY
much of the growth as possible. Accordingly, under gas anesthesia, a cau~ery excision of the growth was performed. During the procedure, all areas where the melanoma had reached the surface, were fulgurated with the electric current. Following the operative procedure, the patient was more comfortable, but continued to lose considerable weight and developed a moderately severe cough. On Feb. 21, ]937, the patient began to develop symptoms of pulmonary congestion and thereafter the course was progressively downward and termin~ted in death on March l, 1937. Autopsy revealed melanoma of the vulva with metastases to inguinal lymph nodes, lungs, stomach, and pancreas. Both lungs were riddled with tumor nodules which varied in size from that of a pea to tha~ of a plum. The metastasis to the stomach consisted of a small, flat, white nodule on the greater curvature. The metastasis to the pancreas was not seen in the gross examination of the organ, but microscopically consisted of a circumscribed mass of tumor tissue in which the cells were spindle shaped. In the lymph nodes, the lymphoid tissue was entirely replaced by tumor, with large areas of hemorrhage and necrosis. Acknowledgement is here made to Dr. B. Z. Cashman for permission to report this case: to Dr. Mortimer Cohen for the pathological data; and to Miss Ann Shiras for the photographs. 3710 F~FTH AVENUE.
CARCINOMA OF THE C E R V I X DURING PREGNANCY a SAMUEL GOLDSTEIN,
B.S., M.D., F.A.C.S., PITTSBURGH,
])A.
ARCINOMA of the cervix, being found so rarely as a complication of pregnancy, especially in women who are pregnant for the first time, prompted us to report this case.
C
CASE J-6234.~A white patient, E. P., aged 22 years, was admitted to the Gynecological Service of Dr. T. B. Carroll in the Montefiore Hospital on Aug. 27, 1937. She was seen the week prior in the Obstetrical Out-patient Department. Her chief complaint was that one week before admittance to the hospital, she had noticed spotting after coitus for the first time. This bleeding was painless. For a month or so prior to this, she had noticed a white vaginal nonodorous discharge. Her menstrual history showed nothing irregular. Puberty occurred at sixteen years of age, her periods being regular, every twenty-eigt~t days, lasting five days, and of moderate amount. Her last menstrual perio~l was on Feb. 19, 1937 and of the usual duration. Patient had been married one year and had never been pregnant before. No history of abortions or miscarriages. Her family history showed no evidence of cancer or tuberculosis. Her father and mother, two brothers, and two sisters, are all living and well. Abdominal examina¢ion revealed the abdomen enlarged to the size of about six months' pregnancy. The baby was in R. O.A. position with fetal heart sounds heard in the right lower quadrant. Vaginal Examination: Attached to the anterior lip of the cervix was a soft, friable, everting, cauliflower, vascular mass, the size of a lemon, attached by a short pedicle. The uterus was not fixed, the fornices were clear, and the tumor with the cervix could be delivered entirely outside of the vagina. A t first, one thought of the possibility of malignant degeneration of a cervical polyp. On Sept. 2, 1937 the patient was operated upon and the mass was removed with its amall pedicte with the actual cautery. On Sept. 7, 1937 patient WaS in. excellen~ condition but said that she felt no fetal movements. Fetal heart sounds could.not be heard. On Sept. 9, 1937 patient delivered herself of a macerated fetus, spontaneously, with no complications. On Sept. 20, 1937 patient received a eouree o f *Read at a meeting of the Pittsburgh Obstetrical and Gynecological Society, ~br--uary 7, 1935.
AMERICAN JOURNAL OF OBSTETRICS AND GYNECO]~OGY
to the site of torsion. There was no evidence of inflammation. The opposite adnexa were normal. This case may be therefore viewed as one of segmental torsion and necrosis of a previously normal tube occurring in a young virgin. ]530 PRESIDENT STREET
MELANOMA
OF
TtIE
V U L V A ~:~
R . CHARLES NUCCI, M . D . , F . A . C . S . , PITTSBURGH, PA.
(From the 1)epart,ment of Gynv(~ology of the Elizabeth ~gteel Magec Hospital and the University o1 Pittsbt~r.qh.) UPANG the past year it has been the writer's goo(] fl)rtune to chance upon a very infrequent ~ype of malignancy of the vulva, namely, malignant melanoma. Mrs. M. I., a 76-year-old white woman, was seen in the Magee Dispensary complaining of "~lumps" in the vulva and both inguinal legions. The patient stated that she h~t always had a small mole on l]Jc righ~ labium majus. In October. 1932 she first noticed black " l u m p s " on the right vulva, which were painless. Four months later they began to bleed and were considerably larger. On Feb. 13. 1936. " l u m p s " were observed in the right groin, following three operations a month previously under local anesthesia. Six weeks before admission the patient felt additional " ' l u m p s " in the left groin. At this time she had had a serosanguineous vaginal discharge for about eighteen months. The " l u m p s ~' had been painful for about two years and were becoming progressively larger. She had lost only a slight amount of weight. Associated symptoms included headache, blurring of vision, tinnitus, and episodes of abdominal discomfort following ingestion of fried foods. The menstrual history was normal and the menopause occurred at the age of fifty. She had had two normal ~ull-term pregnancies. The past medical history included ~yphoid, measles, influenza, and diphtheria. The famil$ history was negative for malignancy. There was marked wrinkling of the skin. The vessels were hard, tortuous, and sclerosed. She had complete dentures. The tonsils were enlarged. The heart was not enlarged but a few premature bea~s were noted. There was slight 1)retibial edema. The vulvar lesion (F~g. 1) consisted of a large somewhat nodular mass. irregularly the size of a ~angerine, occupying the entire right labium minor and of a purplish color. The lower surface of the mass presented some ulceration and extended out to the clitoris, prepuce, upper part of left labium minor, and had infiltrated through so that there were several pigmen?~ed spots, of various sizes, on the outer surface of the right labium major. There were large firm masses in both inguinal regions. Laboratory findings. The urine was negative except for a few white blood corpuscles. I t was negative for melanin. Blood count: 1~. B. C., 3,690,000; W. B. C., 5,550; polymorphonuclears, 56 per cen¢; lymphocytes, 43 per cent. The blood sugar was 120 mg. Nonprotein nitrogen was 24.3 mg. Kahn was negative. Sedimentation time was 20 rain. Course ~ hospital. On Dec. 21. ]936, under gas-ether anesthesia a biopsy was taken and four radium needles, containing 1 2 ~ rag. of radium each, were inserted directly into the vulvar mass. for a period of forty-eight hours (2,400 rag. hr. of radiation). Pathologiv tCvport l~'rom Biopsy. The tumor (Fig. 2) was composed o f a itleoo morphic type of ceil, varying from spindle cell type to a large epithelial type. The cells varied in their melanin content, some o f them being melanin free, aad othera
D
*Read at a meeting of the Pittsburgh Obstetrical and Gynecological Society, February 7, 1938.
~ucc~:
MFZ~ANOMA OF VULVA
513
so packed with pigment that the cell outline was lost. There were ureas of necrosis, but for the most part the tumor was quite cellular. With the Wilder silver stain, some of the spindle-shaped cells had fibrils, while other cells were devoid of fibrils. The fibril-free cells predominated. The distribution of the pigment varied in different cells, some of the cells being so packed with pigment as to render obscure the cell 'outlines, while other cells were devoid of pigment. Diagnosis : Melanoma of the vulva.
Fig. 1.
Fig. 2. Following radiation, the muss seemed to shrink to about two-thirds of its former size and was the seat of a profuse seropurulent exudate, with the patient experiencing considerable discomfort in this area. On Jan. 17, 1937, under nitrous oxide anesthesia, radium needles were again inserted, this time around the periphery of the tumor and allowed to remain in situ for forty-eight hours (2400 mg. hr. of radiation). Symptoms continued practically the same, the patient losing ground very rapidly. On Feb. 10, 1937, about seven weeks after the initial radiation, due to the extreme discomfort of the lesion to the patient, it was decided to excise as
514
AMERICAN"JOURNAL OF OBSTETRICS AND GYNECOI.A)GY
much of the growth as possible. Accordingly, under gas anesthesia, a cau~ery excision of the growth was performed. During the procedure, all areas where the melanoma had reached the surface, were fulgurated with the electric current. Following the operative procedure, the patient was more comfortable, but continued to lose considerable weight and developed a moderately severe cough. On Feb. 21, ]937, the patient began to develop symptoms of pulmonary congestion and thereafter the course was progressively downward and termin~ted in death on March l, 1937. Autopsy revealed melanoma of the vulva with metastases to inguinal lymph nodes, lungs, stomach, and pancreas. Both lungs were riddled with tumor nodules which varied in size from that of a pea to tha~ of a plum. The metastasis to the stomach consisted of a small, flat, white nodule on the greater curvature. The metastasis to the pancreas was not seen in the gross examination of the organ, but microscopically consisted of a circumscribed mass of tumor tissue in which the cells were spindle shaped. In the lymph nodes, the lymphoid tissue was entirely replaced by tumor, with large areas of hemorrhage and necrosis. Acknowledgement is here made to Dr. B. Z. Cashman for permission to report this case: to Dr. Mortimer Cohen for the pathological data; and to Miss Ann Shiras for the photographs. 3710 F~FTH AVENUE.
CARCINOMA OF THE C E R V I X DURING PREGNANCY a SAMUEL GOLDSTEIN,
B.S., M.D., F.A.C.S., PITTSBURGH,
])A.
ARCINOMA of the cervix, being found so rarely as a complication of pregnancy, especially in women who are pregnant for the first time, prompted us to report this case.
C
CASE J-6234.~A white patient, E. P., aged 22 years, was admitted to the Gynecological Service of Dr. T. B. Carroll in the Montefiore Hospital on Aug. 27, 1937. She was seen the week prior in the Obstetrical Out-patient Department. Her chief complaint was that one week before admittance to the hospital, she had noticed spotting after coitus for the first time. This bleeding was painless. For a month or so prior to this, she had noticed a white vaginal nonodorous discharge. Her menstrual history showed nothing irregular. Puberty occurred at sixteen years of age, her periods being regular, every twenty-eigt~t days, lasting five days, and of moderate amount. Her last menstrual perio~l was on Feb. 19, 1937 and of the usual duration. Patient had been married one year and had never been pregnant before. No history of abortions or miscarriages. Her family history showed no evidence of cancer or tuberculosis. Her father and mother, two brothers, and two sisters, are all living and well. Abdominal examina¢ion revealed the abdomen enlarged to the size of about six months' pregnancy. The baby was in R. O.A. position with fetal heart sounds heard in the right lower quadrant. Vaginal Examination: Attached to the anterior lip of the cervix was a soft, friable, everting, cauliflower, vascular mass, the size of a lemon, attached by a short pedicle. The uterus was not fixed, the fornices were clear, and the tumor with the cervix could be delivered entirely outside of the vagina. A t first, one thought of the possibility of malignant degeneration of a cervical polyp. On Sept. 2, 1937 the patient was operated upon and the mass was removed with its amall pedicte with the actual cautery. On Sept. 7, 1937 patient WaS in. excellen~ condition but said that she felt no fetal movements. Fetal heart sounds could.not be heard. On Sept. 9, 1937 patient delivered herself of a macerated fetus, spontaneously, with no complications. On Sept. 20, 1937 patient received a eouree o f *Read at a meeting of the Pittsburgh Obstetrical and Gynecological Society, ~br--uary 7, 1935.