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Pyometra following application of radium for carcinoma of the cervix
iiiderablc amount c>f pale Rtainink f acidonhilic t,ytoplasm and a. uncleus which is fairly large, oral, and vesicular. In son,, arc3s the lining epithelium of the gland T11c tumor is nlod~~rately v:~scular. spaces has undergone hydroJbhi(: cltangrs. In conclusion Our diagnosis is bnsed: First:
On
the
&feminizing
eifret
of
this
tumor
with
subxqucnt
masculiniza~
tion. 111’ the normal feminine function on tho oblation Second : On the rrstoratitrll of this tumor. Third : On its unmistakable histologic appearance. Fourth : That a differentiation from the so-called “ neminoma’ ’ is made by being cognizant of the first two points of our conclusion and the absence of leucocytir infiltration of the tumor.
My thanks :trr clut: to Pmfesaor T. S. Welton for the privilege of reporting this ci~se, as it occurred on his service zt Greenpoint Hospital., and to Dr. M. Glass, whosr persistent study of the cast. ai(1f.d ms in wriving at this Anal diagnosis.
DR. JAMES Ii. GOODALL.---I have had the privilege of seeing four arrhenoblastomas, but this one presents the most normal arrangement of cells and tubules of any that I haye seen, either under the microscope or in mierophotographs. Robert Meyer classified these arrhenoblastomas into three groups, in the first of which are the typical t,estieular tubules, such as Dr. Phelan’s case depiots, but in which Meyer states masculinization of the woman does not occur. Here is one exoeption. On the other hand mp own case is of the atypical form, in which Meyer states that there are always sex changes, but in my case they were conspicuously absent. So that on the score of these two cases Robert Meyer’s artificial subdivision, as to the presence or absence of sex change, completely collapses. DR.. SAMUEL secretion which of the suprarenal pituitary, produce organs of internal ifestations.
A. WOLF%.---There are disturbances in other organs of inbernal produce masculinizing effects. Simple hyperplasia and tumors cortex, as well as basophilic tumors of the anterior lobe of tho hirsuties and amenorrhea, if not external hermaphroditism. Three secretion, therefor<~, or
PYOMETRA
FOLLOWING CARCINOMA
APPLICATION OF RADIUM OF THE CERVIX”
WITH THE LATE DEVELO~~~T OF ADENOCABCINONA
FOR
OF THE
BODY OF THE ~~TERERUS AARON (From.
HIRSCH, M.D., BROOKLYN, N. Y.
the Gynecoiogica,l
SerGcr
of Beth
Moses
Hospital)
PYOMETRA
following the application of radium for carcinoma of the cervix is apparently not a very frequent complication. However, in reviewing the literature, one realizes that. the condition is met often enough to warrant more careful ccmsideration. P. B. Bland states that AIdmanni found pyometra in 3.3 per c&it of Lomon found a like percentage; S&ncervical cancers following radium therapy; clair 6.2 per cent; Tate 10.7 per cent; Norris in 600 case8 reports 5 cases, and Polak
*Presented at a meeting of the ErcokIyn
Gynecological
Society, Nareh 3, 1953.
HIRSCH
:
751
PTCkME’PRA
Bland, personally, does not believe reports 7 cases. Kelly also had several cases. it exceeds one-half of 1 per cent. Bartlett and Smith, in a review of 673 cases, report 19 cases of pyometra with only 2 cases secondary to radium therapy, with The number of cases actually subsequent stenosis, an incidence of 0.69 l)er cent. reported are few. Bland reports 3 cases, E. Hortini 1 case, J. (ingot, .Jenneney and Varrm also report 1 cast. The Jtaliari, Russian and Dutch also report an occasional CitSC.
Mrs. T. G., married, sixty years of age, was well up to 1924. She then consulted her family physician because she had been staining occasionally for the past month, on going to the toilet. She had been pregnant four times and had three living children, having had one miscorriagc in 1902. She had had her menopause at fortyfive years of age. There were no other symlnoms and her general physical condition was good. A provisional diagnosis of carcinoma of the cervix was made, and she Jvas referred He made a diagnosis of squ”mous cell carcinoma to Dr. H. C. Bailey of Manhattan. ,She was under the observation of of the cervix and instituted radium treatment. Dr. Bailey and her family physician. 8ince there were no recurrences and the cervix was healed, she was discharged as cured after a. fit--c-year period. In August, 1932, the patient again consulted her family physician. About six months previously she began to feel a sensation of fullness in her pelvis. This grew worse until it became a sense of weight. She also felt a dragging sensation, had increased frequency of urination, but no dysuria. Neither vaginal bleeding nor purulent discharge was present. Her weight rvas stationary at 165 pounds for the past few years. Her general condition was good. With the’ above history she was admitted to Beth Moses Hospital in good physical condition. Abdominal examination showed a. mobile mass in the hypogastrie region extending to both iliac fossae. It was not tender. lntroitus somewhat shrunken as result of beginning senile atrophy. Cervix small, smooth, hard, fibrotic (postradiation), high in the vault of the vagina.. The uterus was the size of a. 5 months’ gestation, firm, somewhat irregular in outline, mobile and not t.ender. No adnexal masses palpated. Parametrin were free and no palpablc pelvic or inguinxl glands. Diag,iosis.-Fibroids
of
the
uterus.
On Aug. 18, 1932, she was operated upon. Under spinal anesthesia, was opened with a low midline incision. The uterus was found to be months’ gestation, soft, cystic, and regular. On puncturing the tenaculum forceps, about one quart of thick, chocolatc-colored fluid A panhysterectomy was performed. great tension. The abdomen layers without drainage. The patient had a prolonged convalrscenre~ due to a left parametritis, course of which it was found necessary to perform a colpotomy. On October 12, the patient was discharged from the hospital in condition. Her temperature, pulse, and respirations were normal. pelvic exudate was present. There was scant vaginal drainage.
the abdomen the size of a 5 tumor with a escaped under was closed in during
the
good general No palpable
PATHOLOGY Specimen consisted of a uterus, cystic in consistency, measuring 7 by 6 by 4 cm. Upon opening the uterus along its anterior wall in the usual fashion, the endometrial cavity was found to be the size of an orange (as a result of shrinkage following Very little purulent material was found. There were also the evacuation of pus). The endometrial wall was ragged and two small shreds of necrotic material. presented a honeycombed appearance with excavations varying in size from 2 to 8 mm. in diameter. The entire internal lining was markedly congested and hemor-
rhagic. In certain areas t,herc were greenish-yellow discolorations. The the excavations were composed of similar types of tissnr. The myometrium in thickness from 1.5 to 2 cm.
bases of raricd
XiErosoopia--The ~~11 of the uterus was much thinnrtl out aad showed ill. numerable scars in the mFomrtrium with oblit.erztcd, scsarred blood vessels and lberivascular accumulations of lymphocytes, plasma cells and polynnclear leucn+ytrs. Excqlt in oee;\sional scaitered areas, the rndometrium was not present. TIIP I.:cvitT was lined hy granulation tissue with hemorrhages and infiltrations of plasma cells and lcucocytts. Jn one small area there were found a few small glandular structures with nuclear rind rytopbsmiP at*ypism and invasion of the underlying I’onne(Btive tissue and myometrium by single (aells and strands of epithelium. D
with
chronic
met,ritis
and
adenoearcinoma
of thtl
tjcrdp
of
COMMENT This nase illustrates the difficulties in the diagnosis of yyometra. Given a historI together with the development of of having received radium therapy previously, midpelvic pain increasing in severity, pyometra should be borne in mind, especially if a globular mass is present in t.he suprapubic region. The cervix should be inIf complete atresia is found the spected and the passage of a. sound a.t.tempted. diagnosis is certain. The apparent well-being of this patient, the lack of cachexia: the normal temperaturej the stationarT weight are all misleading fact,ors in the diagnosis of pyometra. One other feature of interest in this case is the finding of an adenocareinoma in the body of the uterus eight years following irradiation for carcinoma of the 1 was able to find two such cases in the literature. One reported bp cervix. The carcinoma of the body of the uterus must Bland, and the other by Bortini. It was an adenocarcinoma whereas that I,e considered as an independent growth. It must also be borne in mind that of the cervi.x was a squamous cell neoplasm. the adenocarcinoma of the fundus could not have produced the pyometra since it was entirely microscopic in size, having been found only after careful examination of the wall of the uterus and then in only one section. From this point of view below, hut that the pat,ient
it was fortunate was given the
that benefit
the uterus was not of a hysterectomy.
emptied
from
REFERENCES Am. J. Obst. & Gynee. 17: 528, 192,9. (1) Bland, P. B.: (3) Bwtimi, 3.: Ann. di 3stet. 51: 1333, 1929. (3) Esw~, X,: Monatsehr. f. Geburtsh. u. Gyniik. 77: 217, 1927. (4) GwilhR?n. a& Gmy: Yresse med. 40: 242, 1932. (5) Gq#, J., Jeanwney, wnd Farrim: Bull. See. d’obst. et de gynec. 17: 245, 1928. (6) E+&, W. B.: Viriginia M. Monthly 57: 451, 1930. (7) Prtids, C. B.: West Virginia M. J. 25: Am. J. Roentgenol. 19: 323, 1928. (9) violet: Lyon 417, 1929. (8) stwy, L. J.: ned. 139: 694, 1927. 328
NEW
YORK
AVENUE
DISCUSSION DR. DAVID FEINER.-We thought it best to remove the entire uterus rather .han take a chance on a recurrence of this condition, in vie\r of the faulty drainage )f the lower uterine segment. The subsequent finding of carcinoma in the funaal segion amply justified what might at first sight a,ppear to have been a rather radical xocedure. The one difficulty we had postoperative was a parametritis which nacessi&ed a posterior colpotomy, and it is very likely that this could have been avojded f we had not omitted vaginal drainage at the original operation.
On
the
&feminizing
eifret
of
this
tumor
with
subxqucnt
masculiniza~
tion. 111’ the normal feminine function on tho oblation Second : On the rrstoratitrll of this tumor. Third : On its unmistakable histologic appearance. Fourth : That a differentiation from the so-called “ neminoma’ ’ is made by being cognizant of the first two points of our conclusion and the absence of leucocytir infiltration of the tumor.
My thanks :trr clut: to Pmfesaor T. S. Welton for the privilege of reporting this ci~se, as it occurred on his service zt Greenpoint Hospital., and to Dr. M. Glass, whosr persistent study of the cast. ai(1f.d ms in wriving at this Anal diagnosis.
DR. JAMES Ii. GOODALL.---I have had the privilege of seeing four arrhenoblastomas, but this one presents the most normal arrangement of cells and tubules of any that I haye seen, either under the microscope or in mierophotographs. Robert Meyer classified these arrhenoblastomas into three groups, in the first of which are the typical t,estieular tubules, such as Dr. Phelan’s case depiots, but in which Meyer states masculinization of the woman does not occur. Here is one exoeption. On the other hand mp own case is of the atypical form, in which Meyer states that there are always sex changes, but in my case they were conspicuously absent. So that on the score of these two cases Robert Meyer’s artificial subdivision, as to the presence or absence of sex change, completely collapses. DR.. SAMUEL secretion which of the suprarenal pituitary, produce organs of internal ifestations.
A. WOLF%.---There are disturbances in other organs of inbernal produce masculinizing effects. Simple hyperplasia and tumors cortex, as well as basophilic tumors of the anterior lobe of tho hirsuties and amenorrhea, if not external hermaphroditism. Three secretion, therefor<~, or
PYOMETRA
FOLLOWING CARCINOMA
APPLICATION OF RADIUM OF THE CERVIX”
WITH THE LATE DEVELO~~~T OF ADENOCABCINONA
FOR
OF THE
BODY OF THE ~~TERERUS AARON (From.
HIRSCH, M.D., BROOKLYN, N. Y.
the Gynecoiogica,l
SerGcr
of Beth
Moses
Hospital)
PYOMETRA
following the application of radium for carcinoma of the cervix is apparently not a very frequent complication. However, in reviewing the literature, one realizes that. the condition is met often enough to warrant more careful ccmsideration. P. B. Bland states that AIdmanni found pyometra in 3.3 per c&it of Lomon found a like percentage; S&ncervical cancers following radium therapy; clair 6.2 per cent; Tate 10.7 per cent; Norris in 600 case8 reports 5 cases, and Polak
*Presented at a meeting of the ErcokIyn
Gynecological
Society, Nareh 3, 1953.
HIRSCH
:
751
PTCkME’PRA
Bland, personally, does not believe reports 7 cases. Kelly also had several cases. it exceeds one-half of 1 per cent. Bartlett and Smith, in a review of 673 cases, report 19 cases of pyometra with only 2 cases secondary to radium therapy, with The number of cases actually subsequent stenosis, an incidence of 0.69 l)er cent. reported are few. Bland reports 3 cases, E. Hortini 1 case, J. (ingot, .Jenneney and Varrm also report 1 cast. The Jtaliari, Russian and Dutch also report an occasional CitSC.
Mrs. T. G., married, sixty years of age, was well up to 1924. She then consulted her family physician because she had been staining occasionally for the past month, on going to the toilet. She had been pregnant four times and had three living children, having had one miscorriagc in 1902. She had had her menopause at fortyfive years of age. There were no other symlnoms and her general physical condition was good. A provisional diagnosis of carcinoma of the cervix was made, and she Jvas referred He made a diagnosis of squ”mous cell carcinoma to Dr. H. C. Bailey of Manhattan. ,She was under the observation of of the cervix and instituted radium treatment. Dr. Bailey and her family physician. 8ince there were no recurrences and the cervix was healed, she was discharged as cured after a. fit--c-year period. In August, 1932, the patient again consulted her family physician. About six months previously she began to feel a sensation of fullness in her pelvis. This grew worse until it became a sense of weight. She also felt a dragging sensation, had increased frequency of urination, but no dysuria. Neither vaginal bleeding nor purulent discharge was present. Her weight rvas stationary at 165 pounds for the past few years. Her general condition was good. With the’ above history she was admitted to Beth Moses Hospital in good physical condition. Abdominal examination showed a. mobile mass in the hypogastrie region extending to both iliac fossae. It was not tender. lntroitus somewhat shrunken as result of beginning senile atrophy. Cervix small, smooth, hard, fibrotic (postradiation), high in the vault of the vagina.. The uterus was the size of a. 5 months’ gestation, firm, somewhat irregular in outline, mobile and not t.ender. No adnexal masses palpated. Parametrin were free and no palpablc pelvic or inguinxl glands. Diag,iosis.-Fibroids
of
the
uterus.
On Aug. 18, 1932, she was operated upon. Under spinal anesthesia, was opened with a low midline incision. The uterus was found to be months’ gestation, soft, cystic, and regular. On puncturing the tenaculum forceps, about one quart of thick, chocolatc-colored fluid A panhysterectomy was performed. great tension. The abdomen layers without drainage. The patient had a prolonged convalrscenre~ due to a left parametritis, course of which it was found necessary to perform a colpotomy. On October 12, the patient was discharged from the hospital in condition. Her temperature, pulse, and respirations were normal. pelvic exudate was present. There was scant vaginal drainage.
the abdomen the size of a 5 tumor with a escaped under was closed in during
the
good general No palpable
PATHOLOGY Specimen consisted of a uterus, cystic in consistency, measuring 7 by 6 by 4 cm. Upon opening the uterus along its anterior wall in the usual fashion, the endometrial cavity was found to be the size of an orange (as a result of shrinkage following Very little purulent material was found. There were also the evacuation of pus). The endometrial wall was ragged and two small shreds of necrotic material. presented a honeycombed appearance with excavations varying in size from 2 to 8 mm. in diameter. The entire internal lining was markedly congested and hemor-
rhagic. In certain areas t,herc were greenish-yellow discolorations. The the excavations were composed of similar types of tissnr. The myometrium in thickness from 1.5 to 2 cm.
bases of raricd
XiErosoopia--The ~~11 of the uterus was much thinnrtl out aad showed ill. numerable scars in the mFomrtrium with oblit.erztcd, scsarred blood vessels and lberivascular accumulations of lymphocytes, plasma cells and polynnclear leucn+ytrs. Excqlt in oee;\sional scaitered areas, the rndometrium was not present. TIIP I.:cvitT was lined hy granulation tissue with hemorrhages and infiltrations of plasma cells and lcucocytts. Jn one small area there were found a few small glandular structures with nuclear rind rytopbsmiP at*ypism and invasion of the underlying I’onne(Btive tissue and myometrium by single (aells and strands of epithelium. D
with
chronic
met,ritis
and
adenoearcinoma
of thtl
tjcrdp
of
COMMENT This nase illustrates the difficulties in the diagnosis of yyometra. Given a historI together with the development of of having received radium therapy previously, midpelvic pain increasing in severity, pyometra should be borne in mind, especially if a globular mass is present in t.he suprapubic region. The cervix should be inIf complete atresia is found the spected and the passage of a. sound a.t.tempted. diagnosis is certain. The apparent well-being of this patient, the lack of cachexia: the normal temperaturej the stationarT weight are all misleading fact,ors in the diagnosis of pyometra. One other feature of interest in this case is the finding of an adenocareinoma in the body of the uterus eight years following irradiation for carcinoma of the 1 was able to find two such cases in the literature. One reported bp cervix. The carcinoma of the body of the uterus must Bland, and the other by Bortini. It was an adenocarcinoma whereas that I,e considered as an independent growth. It must also be borne in mind that of the cervi.x was a squamous cell neoplasm. the adenocarcinoma of the fundus could not have produced the pyometra since it was entirely microscopic in size, having been found only after careful examination of the wall of the uterus and then in only one section. From this point of view below, hut that the pat,ient
it was fortunate was given the
that benefit
the uterus was not of a hysterectomy.
emptied
from
REFERENCES Am. J. Obst. & Gynee. 17: 528, 192,9. (1) Bland, P. B.: (3) Bwtimi, 3.: Ann. di 3stet. 51: 1333, 1929. (3) Esw~, X,: Monatsehr. f. Geburtsh. u. Gyniik. 77: 217, 1927. (4) GwilhR?n. a& Gmy: Yresse med. 40: 242, 1932. (5) Gq#, J., Jeanwney, wnd Farrim: Bull. See. d’obst. et de gynec. 17: 245, 1928. (6) E+&, W. B.: Viriginia M. Monthly 57: 451, 1930. (7) Prtids, C. B.: West Virginia M. J. 25: Am. J. Roentgenol. 19: 323, 1928. (9) violet: Lyon 417, 1929. (8) stwy, L. J.: ned. 139: 694, 1927. 328
NEW
YORK
AVENUE
DISCUSSION DR. DAVID FEINER.-We thought it best to remove the entire uterus rather .han take a chance on a recurrence of this condition, in vie\r of the faulty drainage )f the lower uterine segment. The subsequent finding of carcinoma in the funaal segion amply justified what might at first sight a,ppear to have been a rather radical xocedure. The one difficulty we had postoperative was a parametritis which nacessi&ed a posterior colpotomy, and it is very likely that this could have been avojded f we had not omitted vaginal drainage at the original operation.