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Primary fibromyxochondrosarcoma of endometrial stroma
PRIMARY
FIBROMYXOCHONDROSARCOMA OF ENDOMETRIAL STROMA*
FRED
W.
RANKIN,
M.D., AND ALBERT
C.
BRODERS, M.D.
ROCHESTER, MINN.
A
LTHOUGH fibromyxochondrosarcoma (osteogenic sarcoma) is not an uncommon neopIasm of bone and
account of shght menorrhagia, Ieucorrhea and metrorrhagia. AIthough she was much better after this, she stiI1 compIained of Ieucorrhea and frequency of urination. A few months before admission the Ieucorrhea became worse and was bIood-stained; accompanying this were periods of profuse menstrua1 bIeeding Iasting five days. There were aIso cramping peIvic pains with the passage of cIots. MenstruaI periods were reguIar. On genera1 examination the bIood pressure, puIse and temperature were found to be norma1. A catheterized specimen of urine showed pus, graded I (8 ceI1.s). Erythrocytes and Ieucocytes were normaI. The hemogIobin was of 66 per cent (I I. I gm.). Roentgenograms the thorax and peIvis were negative. Teeth and tonsiIs were infected. There was an abdomina hernia at the site of the Iaparotomy scar. The uterus was enlarged to three times normal size and was irreguIar in outhne. The cervix situated on posterior FIG. I. Fibromyxochondrosarcoma endometriai walI. It presents a cauliflower-like was enIarged and contained a cauIiAower-Iike appearance similar to a papiIIary adenocarcinoma. uIcerating bIeeding mass with severa small noduIes around it. A preoperative diagnosis was cartiIage, its presence as a primary growth made of fibromyomas of the uterus, peIvic in the endometria1 stroma is so rare that inff ammatory disease and post-operative it borders on the unique. The foIIowing is hernia. the report of such a case recentIy observed May g, tota abdomina1 hysterectomy was by us. done, with biIatera1 saIpingo-oophorectomy, appendectomy and repair of the abdomiA coIored woman, aged thirty-six years, came na1 hernia. The patient’s convaIescence was to The Mayo CIinic May 6, 1930, compIaining uneventfu1. of eighteen of menorrhagia and Ieucorrhea On. examination of the tissue removed at months’ duration, She had been married twice, operation biIatera1 chronic saIpingitis and and had had two chiIdren, both aIive and weI1, perisaIpingitis, and biIatera1 chronic cystic and two miscarriages by her first marriage; oophoritis and perioopheritis were found and pregnancy had not occurred after the second The menses began at the age of both tubes were firmIy adhered to the ovaries. marriage. The Iargest cyst in the right ovary was 1.5 cm. eIeven years, were reguIar and somewhat painin diameter; the Iargest cyst in the Ieft ovary fu1. In 1927, Iaparotomy had been performed was 2 cm. in diameter. In the edge of the right eIsewhere for a peIvic abscess, after which there had been a gradua1 onset of frequency of ovary was a fibromyoma 1.5 cm. in diameter. The appendix was chronicaIIy inffamed. There urination, burning, genera1 maIaise and fever, were muItipIe smaI1 fibromyomas of the myopeIvic pain, vagina1 discharge, menorrhagia and metrium. On the posterior endometria1 waI1, metrorrhagia over a period of three months. projecting into the cavity, was a soft, geIatiShe improved after the operation aIthough nous, cartiraginous, cauIiff ower-Iike growth, 8 there was considerabIe drainage for four by 7 by 3.5 cm. (Fig. I). The tumor had infiImonths. Six months before she came to the cIinic diIatation and curettage were done on trated the myometrium to a slight degree. This * Submitted for pubIication January 16, 193 I. 74
NEWSERIES VOL.XII, NO.I Rankin,
Broders-Fibromyxochondrosarcoma
FIG. 2. Fibromyxochondrosarcoma, graded 2, of endometriaI stroma, showing invasion of myometrium by round, ovaI, spindIe, and steIlate ceIIs.
Ame&an
Journal of Surgery
75
FIG. 3. An area in which part of the ceIIs retain the form of those presented in Fig. 2 and others are differentiating into cartilage.
tumor presented a diverse histologic picture. The ceIIs situated between the endometria1 gIands and in the musculature were round, oval, spindle, and steIIate (Fig. 2). They appeared to be differentiating into fibrous and myxomatous tissue. Mitotic figures were not infrequentIy seen. Other areas showed that the tumor was retaining to some extent the ceIIuIar structure described, but at the same time part of the ceIIs were differentiating into cartiIage (Fig. 3) ; other areas showed pure cartiIage, free from mitosis, and presented the picture of a benign chondroma (Fig. 4). A diagnosis was made of fibromyxochondrosarcoma, graded 2. It is onIy natura1, in commenting on the case, to ask how the presence of a cartiIaginous tumor in an organ where cartiIage is not normaIIy found can be accounted for. Some wiI1 say it was due to the presence of an embryonic rest. This probabIy is not true. It is we11 known that fibrous connective tissue, mucous tissue, and cartiIage are cIoseIy reIated; therefore, it is easy to see how the undifferentiated ceIIs of such tissues couId differentiate into any of them.
FIG. 4. Area showing we11 differentiated from mitosis and presenting a picture in benign chondroma.
cartilage, free Iike that seen
FIBROMYXOCHONDROSARCOMA OF ENDOMETRIAL STROMA*
FRED
W.
RANKIN,
M.D., AND ALBERT
C.
BRODERS, M.D.
ROCHESTER, MINN.
A
LTHOUGH fibromyxochondrosarcoma (osteogenic sarcoma) is not an uncommon neopIasm of bone and
account of shght menorrhagia, Ieucorrhea and metrorrhagia. AIthough she was much better after this, she stiI1 compIained of Ieucorrhea and frequency of urination. A few months before admission the Ieucorrhea became worse and was bIood-stained; accompanying this were periods of profuse menstrua1 bIeeding Iasting five days. There were aIso cramping peIvic pains with the passage of cIots. MenstruaI periods were reguIar. On genera1 examination the bIood pressure, puIse and temperature were found to be norma1. A catheterized specimen of urine showed pus, graded I (8 ceI1.s). Erythrocytes and Ieucocytes were normaI. The hemogIobin was of 66 per cent (I I. I gm.). Roentgenograms the thorax and peIvis were negative. Teeth and tonsiIs were infected. There was an abdomina hernia at the site of the Iaparotomy scar. The uterus was enlarged to three times normal size and was irreguIar in outhne. The cervix situated on posterior FIG. I. Fibromyxochondrosarcoma endometriai walI. It presents a cauliflower-like was enIarged and contained a cauIiAower-Iike appearance similar to a papiIIary adenocarcinoma. uIcerating bIeeding mass with severa small noduIes around it. A preoperative diagnosis was cartiIage, its presence as a primary growth made of fibromyomas of the uterus, peIvic in the endometria1 stroma is so rare that inff ammatory disease and post-operative it borders on the unique. The foIIowing is hernia. the report of such a case recentIy observed May g, tota abdomina1 hysterectomy was by us. done, with biIatera1 saIpingo-oophorectomy, appendectomy and repair of the abdomiA coIored woman, aged thirty-six years, came na1 hernia. The patient’s convaIescence was to The Mayo CIinic May 6, 1930, compIaining uneventfu1. of eighteen of menorrhagia and Ieucorrhea On. examination of the tissue removed at months’ duration, She had been married twice, operation biIatera1 chronic saIpingitis and and had had two chiIdren, both aIive and weI1, perisaIpingitis, and biIatera1 chronic cystic and two miscarriages by her first marriage; oophoritis and perioopheritis were found and pregnancy had not occurred after the second The menses began at the age of both tubes were firmIy adhered to the ovaries. marriage. The Iargest cyst in the right ovary was 1.5 cm. eIeven years, were reguIar and somewhat painin diameter; the Iargest cyst in the Ieft ovary fu1. In 1927, Iaparotomy had been performed was 2 cm. in diameter. In the edge of the right eIsewhere for a peIvic abscess, after which there had been a gradua1 onset of frequency of ovary was a fibromyoma 1.5 cm. in diameter. The appendix was chronicaIIy inffamed. There urination, burning, genera1 maIaise and fever, were muItipIe smaI1 fibromyomas of the myopeIvic pain, vagina1 discharge, menorrhagia and metrium. On the posterior endometria1 waI1, metrorrhagia over a period of three months. projecting into the cavity, was a soft, geIatiShe improved after the operation aIthough nous, cartiraginous, cauIiff ower-Iike growth, 8 there was considerabIe drainage for four by 7 by 3.5 cm. (Fig. I). The tumor had infiImonths. Six months before she came to the cIinic diIatation and curettage were done on trated the myometrium to a slight degree. This * Submitted for pubIication January 16, 193 I. 74
NEWSERIES VOL.XII, NO.I Rankin,
Broders-Fibromyxochondrosarcoma
FIG. 2. Fibromyxochondrosarcoma, graded 2, of endometriaI stroma, showing invasion of myometrium by round, ovaI, spindIe, and steIlate ceIIs.
Ame&an
Journal of Surgery
75
FIG. 3. An area in which part of the ceIIs retain the form of those presented in Fig. 2 and others are differentiating into cartilage.
tumor presented a diverse histologic picture. The ceIIs situated between the endometria1 gIands and in the musculature were round, oval, spindle, and steIIate (Fig. 2). They appeared to be differentiating into fibrous and myxomatous tissue. Mitotic figures were not infrequentIy seen. Other areas showed that the tumor was retaining to some extent the ceIIuIar structure described, but at the same time part of the ceIIs were differentiating into cartiIage (Fig. 3) ; other areas showed pure cartiIage, free from mitosis, and presented the picture of a benign chondroma (Fig. 4). A diagnosis was made of fibromyxochondrosarcoma, graded 2. It is onIy natura1, in commenting on the case, to ask how the presence of a cartiIaginous tumor in an organ where cartiIage is not normaIIy found can be accounted for. Some wiI1 say it was due to the presence of an embryonic rest. This probabIy is not true. It is we11 known that fibrous connective tissue, mucous tissue, and cartiIage are cIoseIy reIated; therefore, it is easy to see how the undifferentiated ceIIs of such tissues couId differentiate into any of them.
FIG. 4. Area showing we11 differentiated from mitosis and presenting a picture in benign chondroma.
cartilage, free Iike that seen