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Tumors of the round ligament
TUMORSOFTHE ROUNDLIGAMENT CYRUS F. HORINE, &I.D., BALTIMORE, MARYLAND (From the Department
K
of Surgery,
School
of Medioine,
University
of Maryland)
W., aged fifty-four, married, entered the Provident Hospital July 2, 1929, complaining of a “swelling in the lower part of the stomach.” The family history and the past history were negative. The patient started menstruating at the age of thirteen years. Regular periods lasted three to four days without excessive bleeding or pain. Menopause occurred ten years previous to time of admission. She had carried and delivered three full-term babies without instrumentation. The physical examination was negative with the exception of the presence of a maas in each inguinal region. These masses had been noticed for a period of one year prior to admission. The mass on the right side appeared to be about the size of an English walnut, sowewhat movable, and not adherent to the overlying .
Fig.
L-This
is a photograph
(actual
size)
of the tumor
described
in the text.
skin. It was fairly firm in consistency, though apparently cystic. The mass on the left side was not quite so large and not so freely movable as the one on the right side. It was more or less “doughy” in consistency. Operation was advised, after a diagnosis of bilateral hydrocde of the canal of Nuck had been made. Both masses were exposed through inguinal incisions under nitrous oxide and ether anesthesia. A hydrocele of the canal of Nuck, found on the right side e’xtending down to the fundus of the bladder, was removed in toto. The tumor of the left inguinal canal was encapsulated and adherent to the extraperitoneal portion of the round ligament. A slightly transparent capsule made us suspicious of an incarcerated hernia. An incision made into the capsule set free about an ounce of straw-colored fluid. The internal inguinal ring could not be found near the mass which was dissected away from the round ligament and enuoleated in toto. A careful examination was made to determine the presence of scar tissue between the capsule There was no SC= tissue present. of the mass and the anterior parietal peritoneum. The capsule of the tumor was of the same thickness throughout. Fatty tissue resembling omentum was suspended by a pedicle within the capsule. The lining of the capsule bad a serous surface resembling peritoneum. The fatty mass may have been embryonic in derivation or it may have been the
446
HORINE:
TUMORS
OF
ROUND
447
IJGAMENT
result of an old strangulation of part of the omentum. an old strangulated omentocde one would expect to capsule and the parietal peritoneum. This, aa mentioned
If its presence was due to find some scar between the above, could not be found.
In addition to this case, we have reviewed 36 cases of the different types of tumors of the round ligament which have been reported since 1914. Prior to 1914, Wells reported 2 cases of fibromyomata in 1865; Saenger in 1882 reported 12 cases of fibromyomata in addition to one case of his own; Emanuel in 1903 collected 80 cases and Taussig found 61 cases of tumor reported from 1903 to 1914, in addition to his own reported case of sarcoma of the round ligament. I have not included the cases of hydrocele in this group but have included two cases of dermoid cysts, one cystic lymphangioma and another cyst thought to have been tuberculous. Guyot and others reported finding a mass which proved to be an inflammatory lymphatic gland. They mention that the presence of glands on the round ligament near the horn of the ut,erus appears to be very rare. The average age in this group is thirty-eight years. The age was not given in five cases. This corresponds to the average age in other reported groups of cases. Winckel found one case in a patient seventy-six years of age, while the youngest reported case has been recorded by niche1 in a newborn child. The youngest case in our group was a child five years of age, reported by Ducuing as having a bilateral lipoma. The oldest case is Gueullette’s case of Wolff’s tumor in a woman sixty-three years of age. This tumor showed malignant degeneration. We found 22 cases where the tumor occurred on the right side, while 9 cases were located on the left side, and 2 cases were bilateral. One of the bilateral cases was lipoma and the other fibromyoma. The location was not given in 3 cases. Emanuel’s review shows a preponderance of tumors of the right side, while Taussig’s report gave almost equal distribution. Ward, Kanther, Vercesi, Sams and Walther reported their cases as having been intraperitoneal. According to Taussig the symptoms of tumors in this location are very slight. A number of this group complained of pain at the site of the tumor during menstruation. Broun’s case of adenomyoma and Sserdjukoff’s case of cystic lymphangioma were given as postoperat,ive cases. Calzavara’s case of osseous tumor was thought to have resulted from an old tnberculous infection. The diagnosis in practically all of this group was made by histopathologic section. The cases are tabulated as follows: Adenomyoms Cystic Fibroma Cystic Lymphangioma Dermoid Cyst Fibroma Fibroleiomyoma
4 1 1 2 6 1
cases ease case cases cases case
Fibrosarcoma Leiomyoa.ngion~a Lipoma Lymph gland in Osseous Tumor Sarcoma
ligament
2 1 1 1 1 2
cases case case ease case cases
448
AMERI(!AN
Fibromyoma Fibromyossrcoma Fibromyxoma P’ibromyxoleiomyoma
JOURNAL
5 1 1 1
OF
OBSTETRICS
cases case case case
AND
CYNECOLOGT
Tuberculous Cyst Varicositics Wolff’s Tumor
1 Cmx! 2 cases L’ cases
REFERENCES
(1) Bichel: Zentralbl. f. Gy&k. 1: 57, 1912. (2) Ballin, M.: Harper’s Hosp. Bull. 1: l-3, Detroit, 1917. (3) Brown, L.: -4m. J. Obst., N. Y. 79: 561-563, 1919. (4) Calzavara, U.: Zentralbl. f. GyaBk. 48: 579-581, 1924. (5) Cernezzi, A. : Pensiero med. 4: 709-712, 1914. (6) Cosentino, A.: Morgagni, Milan0 e Napoli 59: 265-272, 1917. (7) Cullen, !l’. S.: Bull. Johns Hopkins Hosp. 7: 112-114, 1896. (8) Cullen, T. S. : Surg., Gynec. & Obst. 22: 258-260, 1916. (9) Da&win and Berwrdbeig: Bull. Soe. d’obst. et de gym%. 10: 781, 1921. (10) Di Pa&, I;.: Arch. di ostet. e ginec. 25: 11, 78-82, 1924. (11) Dossena, G.: Atti d. Sot. lomb. di SC. med. e biol. 11: 179-189, 1 Pl., 1922. (12) Ducking, J. : Gym%. et obst. 1: 81-93, 1920. (13) Emanuel, R.: Ztsehr. f. Geburtsh. u. Gmk. 48: 383-427, 1903. (14) Ester, Gqnfeltt, and Aties: Bull. et m6m. Sot. Anat. de Paris 91: 240-243, 1921. (15) Gaetu, G.: Policlinico, sez. Prat. Roma 30: 177, 1923. (16) Gwd lette, IE. : Bull. et m6m. Sot. Anat. de Paris 94: 494-498, 1924. (17) Guyot, et al.: J. de m&I. tours de Bordeaux 54: 282, 1924. (18) Hi&cl, P.: Bull. et m6m. Sot. anat. de Paris 93: 299-303, 1924. (19) Horung, R.: Miinchen. med. Wchnschr. 71: 402, 1924, (20) Iraeta: Prensa med. Argentian, Buenos Aires 4: 200, 1917-18. (21) Kunther, H. :‘Monatschr. f. Geburt,sh. -u. Gynlk. 63: 325-330, 1923. (22) Lontbar&, R.: Riforma med. 40: 991-993. 1924. (33) Maccabruni. P.: Ann. di. ostet. e ginoc. 1: 327-337, 1915. (24) Maguton, 0.: Ann. ital. di bhi. 4: 495-504, 1925. (25) Murta, A.: Riforma med. 40: 104-106, 1924. (26) Mestron, W.: Ann. di ostet. e ginec. 45: 221-227, 1923. (27) Moench, G. L.: Med. Rec. N. Y. 97: 653. 1920. (28) Mowh, G.: Deutsche med. Wchnschr. 44: 1021, 1918. (29) Or?%, IIf.: Clin. o&et: 28: 550-554, 1926. (30) Saenger, M.: Arch. f. GynIk. 21: 279, 308, 1883. (31’1 Saww 1;. V.: Colorado Med. 20: 135-138, 1923. (32) Schwurz, 3.: Bull. Wom&,s Hosp. Path. No. 39-44, 1917. (33) Shah, W. F.: J.‘Obst. & Gynec. Brit,. Emp. 32: 121, 1925. (34) Sserdjz&ofl, M. G.: Arch. f. Gmk. 122: 88-101, 1924. (35) Tussig, F. J.: Surg., Gynec. $ Obst. 19: 218-223, 1914. (36) Walther, C.: Rev. mens. de Gynec., Obstet. et de pediat. Par. 14: 60-63, 1919. (37) Warn7, W.: Am. J. Obst., N. Y. 77: 152, 1918. (38) Wells, S.: Brit. M. J. 2: 484, 1865. (39) ran Winckei, (quoted by Vdn Zur-M;hl&, I?.) in Zentralbl. f. Gynsk. 887-880, (40) Vercesi, r.: Folio 1910. Ein Fibromvom des Ligamenturn rotundum uteri. Gynarc., Pavia. 20: 477-500, 1524. 817 PARK
AI’F.NUE.
K
of Surgery,
School
of Medioine,
University
of Maryland)
W., aged fifty-four, married, entered the Provident Hospital July 2, 1929, complaining of a “swelling in the lower part of the stomach.” The family history and the past history were negative. The patient started menstruating at the age of thirteen years. Regular periods lasted three to four days without excessive bleeding or pain. Menopause occurred ten years previous to time of admission. She had carried and delivered three full-term babies without instrumentation. The physical examination was negative with the exception of the presence of a maas in each inguinal region. These masses had been noticed for a period of one year prior to admission. The mass on the right side appeared to be about the size of an English walnut, sowewhat movable, and not adherent to the overlying .
Fig.
L-This
is a photograph
(actual
size)
of the tumor
described
in the text.
skin. It was fairly firm in consistency, though apparently cystic. The mass on the left side was not quite so large and not so freely movable as the one on the right side. It was more or less “doughy” in consistency. Operation was advised, after a diagnosis of bilateral hydrocde of the canal of Nuck had been made. Both masses were exposed through inguinal incisions under nitrous oxide and ether anesthesia. A hydrocele of the canal of Nuck, found on the right side e’xtending down to the fundus of the bladder, was removed in toto. The tumor of the left inguinal canal was encapsulated and adherent to the extraperitoneal portion of the round ligament. A slightly transparent capsule made us suspicious of an incarcerated hernia. An incision made into the capsule set free about an ounce of straw-colored fluid. The internal inguinal ring could not be found near the mass which was dissected away from the round ligament and enuoleated in toto. A careful examination was made to determine the presence of scar tissue between the capsule There was no SC= tissue present. of the mass and the anterior parietal peritoneum. The capsule of the tumor was of the same thickness throughout. Fatty tissue resembling omentum was suspended by a pedicle within the capsule. The lining of the capsule bad a serous surface resembling peritoneum. The fatty mass may have been embryonic in derivation or it may have been the
446
HORINE:
TUMORS
OF
ROUND
447
IJGAMENT
result of an old strangulation of part of the omentum. an old strangulated omentocde one would expect to capsule and the parietal peritoneum. This, aa mentioned
If its presence was due to find some scar between the above, could not be found.
In addition to this case, we have reviewed 36 cases of the different types of tumors of the round ligament which have been reported since 1914. Prior to 1914, Wells reported 2 cases of fibromyomata in 1865; Saenger in 1882 reported 12 cases of fibromyomata in addition to one case of his own; Emanuel in 1903 collected 80 cases and Taussig found 61 cases of tumor reported from 1903 to 1914, in addition to his own reported case of sarcoma of the round ligament. I have not included the cases of hydrocele in this group but have included two cases of dermoid cysts, one cystic lymphangioma and another cyst thought to have been tuberculous. Guyot and others reported finding a mass which proved to be an inflammatory lymphatic gland. They mention that the presence of glands on the round ligament near the horn of the ut,erus appears to be very rare. The average age in this group is thirty-eight years. The age was not given in five cases. This corresponds to the average age in other reported groups of cases. Winckel found one case in a patient seventy-six years of age, while the youngest reported case has been recorded by niche1 in a newborn child. The youngest case in our group was a child five years of age, reported by Ducuing as having a bilateral lipoma. The oldest case is Gueullette’s case of Wolff’s tumor in a woman sixty-three years of age. This tumor showed malignant degeneration. We found 22 cases where the tumor occurred on the right side, while 9 cases were located on the left side, and 2 cases were bilateral. One of the bilateral cases was lipoma and the other fibromyoma. The location was not given in 3 cases. Emanuel’s review shows a preponderance of tumors of the right side, while Taussig’s report gave almost equal distribution. Ward, Kanther, Vercesi, Sams and Walther reported their cases as having been intraperitoneal. According to Taussig the symptoms of tumors in this location are very slight. A number of this group complained of pain at the site of the tumor during menstruation. Broun’s case of adenomyoma and Sserdjukoff’s case of cystic lymphangioma were given as postoperat,ive cases. Calzavara’s case of osseous tumor was thought to have resulted from an old tnberculous infection. The diagnosis in practically all of this group was made by histopathologic section. The cases are tabulated as follows: Adenomyoms Cystic Fibroma Cystic Lymphangioma Dermoid Cyst Fibroma Fibroleiomyoma
4 1 1 2 6 1
cases ease case cases cases case
Fibrosarcoma Leiomyoa.ngion~a Lipoma Lymph gland in Osseous Tumor Sarcoma
ligament
2 1 1 1 1 2
cases case case ease case cases
448
AMERI(!AN
Fibromyoma Fibromyossrcoma Fibromyxoma P’ibromyxoleiomyoma
JOURNAL
5 1 1 1
OF
OBSTETRICS
cases case case case
AND
CYNECOLOGT
Tuberculous Cyst Varicositics Wolff’s Tumor
1 Cmx! 2 cases L’ cases
REFERENCES
(1) Bichel: Zentralbl. f. Gy&k. 1: 57, 1912. (2) Ballin, M.: Harper’s Hosp. Bull. 1: l-3, Detroit, 1917. (3) Brown, L.: -4m. J. Obst., N. Y. 79: 561-563, 1919. (4) Calzavara, U.: Zentralbl. f. GyaBk. 48: 579-581, 1924. (5) Cernezzi, A. : Pensiero med. 4: 709-712, 1914. (6) Cosentino, A.: Morgagni, Milan0 e Napoli 59: 265-272, 1917. (7) Cullen, !l’. S.: Bull. Johns Hopkins Hosp. 7: 112-114, 1896. (8) Cullen, T. S. : Surg., Gynec. & Obst. 22: 258-260, 1916. (9) Da&win and Berwrdbeig: Bull. Soe. d’obst. et de gym%. 10: 781, 1921. (10) Di Pa&, I;.: Arch. di ostet. e ginec. 25: 11, 78-82, 1924. (11) Dossena, G.: Atti d. Sot. lomb. di SC. med. e biol. 11: 179-189, 1 Pl., 1922. (12) Ducking, J. : Gym%. et obst. 1: 81-93, 1920. (13) Emanuel, R.: Ztsehr. f. Geburtsh. u. Gmk. 48: 383-427, 1903. (14) Ester, Gqnfeltt, and Aties: Bull. et m6m. Sot. Anat. de Paris 91: 240-243, 1921. (15) Gaetu, G.: Policlinico, sez. Prat. Roma 30: 177, 1923. (16) Gwd lette, IE. : Bull. et m6m. Sot. Anat. de Paris 94: 494-498, 1924. (17) Guyot, et al.: J. de m&I. tours de Bordeaux 54: 282, 1924. (18) Hi&cl, P.: Bull. et m6m. Sot. anat. de Paris 93: 299-303, 1924. (19) Horung, R.: Miinchen. med. Wchnschr. 71: 402, 1924, (20) Iraeta: Prensa med. Argentian, Buenos Aires 4: 200, 1917-18. (21) Kunther, H. :‘Monatschr. f. Geburt,sh. -u. Gynlk. 63: 325-330, 1923. (22) Lontbar&, R.: Riforma med. 40: 991-993. 1924. (33) Maccabruni. P.: Ann. di. ostet. e ginoc. 1: 327-337, 1915. (24) Maguton, 0.: Ann. ital. di bhi. 4: 495-504, 1925. (25) Murta, A.: Riforma med. 40: 104-106, 1924. (26) Mestron, W.: Ann. di ostet. e ginec. 45: 221-227, 1923. (27) Moench, G. L.: Med. Rec. N. Y. 97: 653. 1920. (28) Mowh, G.: Deutsche med. Wchnschr. 44: 1021, 1918. (29) Or?%, IIf.: Clin. o&et: 28: 550-554, 1926. (30) Saenger, M.: Arch. f. GynIk. 21: 279, 308, 1883. (31’1 Saww 1;. V.: Colorado Med. 20: 135-138, 1923. (32) Schwurz, 3.: Bull. Wom&,s Hosp. Path. No. 39-44, 1917. (33) Shah, W. F.: J.‘Obst. & Gynec. Brit,. Emp. 32: 121, 1925. (34) Sserdjz&ofl, M. G.: Arch. f. Gmk. 122: 88-101, 1924. (35) Tussig, F. J.: Surg., Gynec. $ Obst. 19: 218-223, 1914. (36) Walther, C.: Rev. mens. de Gynec., Obstet. et de pediat. Par. 14: 60-63, 1919. (37) Warn7, W.: Am. J. Obst., N. Y. 77: 152, 1918. (38) Wells, S.: Brit. M. J. 2: 484, 1865. (39) ran Winckei, (quoted by Vdn Zur-M;hl&, I?.) in Zentralbl. f. Gynsk. 887-880, (40) Vercesi, r.: Folio 1910. Ein Fibromvom des Ligamenturn rotundum uteri. Gynarc., Pavia. 20: 477-500, 1524. 817 PARK
AI’F.NUE.