MED. J., (1965), SQUAMOUS IN TERATOMA OF THE OVARY WITH ...
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POSTGRAD. MED. J., (1965), 41, 649 SQUAMOUS CELLED CARCINOMA IN A CYSTIC TERATOMA OF THE OVARY WITH INFECTION JANE M. FULLERTON, M.B., D.P.H., F.C.Path. J. S. TOMKINSON, M.B., F.R.C.S., M.R.C.O.G. Pathologist, Bermondsey and Southwark Hospitals Gynaecologist, New Cross General Hospital, London Group. S.E.14. Obstetric Surgeon, Guy's Hospital, London, S.E.1. DERMOID CYSTS of the ovary account for approx- imately 7% of all ovarian abnormalities but malignant change is rare, occurring only from 0.5% to 5% of cystic teratomas as reported in the literature by Koucky (1925), Weiner (1915), and Peterson (1957) reviewd 222 cases, but of these 103 were not studied and prior to his review the total of cases in the literature was 65 as collected by Hall, Caband and Sullivan (1955). In the following case squamous carcinomatous changes occurred in a cystic dermoid of the ovary and of the malignant changes this is recognised to be the commonest i.e., 88% (Novak, 1958). Other malignant changes seen have included a few cases of sarcoma (Burgess and Shutter, 1954, Peterson, 1957). Case Report In July 1958, Miss A, aged 58, was referred by her doctor to New Cross General Hospital. The patient thought she had "rheumatism of the bowel"; she was losing weight and felt weak and tired. The menarche was at 17 and the menopause at 53, the menstrual cycles Ibeing regular. She had not noticed any recent vaginal bleeding or discharge and micturi- tion was normal. For three weeks she had noticed that her stools were pale but there had not been any alteration in bowel habit. Previously her health had been good, she had not had any operations and had never been pregnant. On examination, she was a pale, emaciated woman with a hirsute chin and with slight ankle oedema. Temperature normal. The abdomen was enlarged by a swelling arising from the pelvis and extending to the umbilicus. There was no tenderness and the surface of the mass was nodular. No free fluid was detected. The liver was enlarged to one finger breadth below the costal margin. As she was virgo intacta, a rectal examination was made which confirmed the presence of a cystic mass in the pelvis. A diagnosis of ovarian carcinoma was made and she was admitted for laparotomy. Pre-operative Investigations: Hb. 43% (7g./100 ml.). Film: Severe normochronic anaemia. Five pints of whole blood were cross matched, three being transfused before the operation. She showed a cold agglutination to a titre of 1 in 200 which was in favour of ,malignancy (Stratton, 1943; Gallico, 1947). Chest X-ray:- Clear lung fields ex- cept for a partly calcified shadow in the second right inter-space. C ·*i.· B I J" FIG. .--Hair ball 10 x 8 x 5 cm. Operation: A week later the abdomen was opened through a left low paramedian incision. Many recent and old adhesions were encountered around a cystic mass which was firmly fixed to the anterior abdominal wall, bladder, colon and rectum and other pelvic organs. Before any dissection was carried out the cyst was seen to be ruptured and leaking offensively smelling sebaceous material containing hairs. It was not Ipossible to identify the ovaries, Fallopian tubes or uterus; these were obliterated and were presumably embedded in the ipelvis and hidden by the firmly adherent lower pole of the tumour. An attempt to dissect the cyst wall was by copyright. on October 19, 2021 by guest. Protected http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/pgmj.41.480.649 on 1 October 1965. Downloaded from
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POSTGRAD. MED. J., (1965), 41, 649
SQUAMOUS CELLED CARCINOMA IN A CYSTIC TERATOMAOF THE OVARY WITH INFECTION
JANE M. FULLERTON, M.B., D.P.H., F.C.Path. J. S. TOMKINSON, M.B., F.R.C.S., M.R.C.O.G.Pathologist, Bermondsey and Southwark Hospitals Gynaecologist, New Cross General Hospital, London
Group. S.E.14.Obstetric Surgeon, Guy's Hospital, London, S.E.1.
DERMOID CYSTS of the ovary account for approx-imately 7% of all ovarian abnormalities butmalignant change is rare, occurring only from0.5% to 5% of cystic teratomas as reported inthe literature by Koucky (1925), Weiner (1915),and Peterson (1957) reviewd 222 cases, butof these 103 were not studied and prior to hisreview the total of cases in the literature was 65as collected by Hall, Caband and Sullivan(1955).
In the following case squamous carcinomatouschanges occurred in a cystic dermoid of the ovaryand of the malignant changes this is recognisedto be the commonest i.e., 88% (Novak, 1958).Other malignant changes seen have included afew cases of sarcoma (Burgess and Shutter, 1954,Peterson, 1957).Case Report
In July 1958, Miss A, aged 58, was referred byher doctor to New Cross General Hospital. Thepatient thought she had "rheumatism of the bowel";she was losing weight and felt weak and tired. Themenarche was at 17 and the menopause at 53, themenstrual cycles Ibeing regular. She had not noticedany recent vaginal bleeding or discharge and micturi-tion was normal. For three weeks she had noticedthat her stools were pale but there had not beenany alteration in bowel habit. Previously her healthhad been good, she had not had any operationsand had never been pregnant.On examination, she was a pale, emaciated woman
with a hirsute chin and with slight ankle oedema.Temperature normal. The abdomen was enlargedby a swelling arising from the pelvis and extendingto the umbilicus. There was no tenderness and thesurface of the mass was nodular. No free fluid wasdetected. The liver was enlarged to one finger breadthbelow the costal margin. As she was virgo intacta,a rectal examination was made which confirmed thepresence of a cystic mass in the pelvis. A diagnosisof ovarian carcinoma was made and she was admittedfor laparotomy.Pre-operative Investigations:Hb. 43% (7g./100 ml.). Film: Severe normochronic
anaemia. Five pints of whole blood were crossmatched, three being transfused before the operation.She showed a cold agglutination to a titre of 1 in 200which was in favour of ,malignancy (Stratton, 1943;Gallico, 1947). Chest X-ray:- Clear lung fields ex-cept for a partly calcified shadow in the secondright inter-space.
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B
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FIG. .--Hair ball 10 x 8 x 5 cm.
Operation: A week later the abdomen was openedthrough a left low paramedian incision. Manyrecent and old adhesions were encountered arounda cystic mass which was firmly fixed to the anteriorabdominal wall, bladder, colon and rectum andother pelvic organs. Before any dissection was carriedout the cyst was seen to be ruptured and leakingoffensively smelling sebaceous material containinghairs. It was not Ipossible to identify the ovaries,Fallopian tubes or uterus; these were obliteratedand were presumably embedded in the ipelvis andhidden by the firmly adherent lower pole of thetumour. An attempt to dissect the cyst wall was
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650 POSTGRADUATE MEDICAL JOURNAL October, 1965
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abandoned land only the superior and posterior wallsof the cyst were removed together with its contentsincluding a hair ball. Swabs were taken of the cystcontents for culture, which grew E. coli, Ps. pyocaneaand a diphtheroid. Infection in a malignant cysticdermoid is claimed to occur in only 0.4% of thecases reported by Blackwell 1(1946) and in Peterson'sseries (1957) only one case with infection was accept-able, the type of organism not being recorded.
Pathological Report of TumourA ruptured cystic tumour containing grossly infected
material and a ihair ball measuring 10 cm. x 8 cm. x5 om. (Fig. 1) filling the cavity was received forexamination. Microscopically the picture was that ofa dermoid cyst showing the presence of ectodermalstructures-squamous epithelial, sebaceous glands andhair follicles-and mesodermal elements in the formof plaques of cartilage. In addition the whole of thewall was infiltrated by squamous celled carcinomashowing many mitotic figures (Fig. 2 and 3).Progress: Two pints of whole blood were trans-fused during and immediately after the operation.Penicillin 500,000 units twice daily was injected forseven days and cystamycin one vial twice daily foreighteen days
She was free of pain until she died on the 51stpost-operative day. A faecal fistula developed throughthe abdominal wound on the 28th day.Unfortunately a post-mortem examination was not
carried out.
SummaryA case of a cystic teratoma of ovary with
squamous carcinomatous changes is reported
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which showed the added features of interest inthe presence of a circulatory cold antibody inthe patient's blood and infection of the cyst cavity.
REFERENCESBLACKWELL, W. J. (1946): Dermoid Cysts of Ovary,
Their Clinical and Pathologic Significance, Amer.J. Obstet. Gynec., 51, 151.
BURGESS, G. F., and SHUTTER, H. W. (1954):Malignancy Originating in Ovarian Dermoids,Obstet. and Gynec., 4, 567.
HALL, J. E., CABAUD, P. G., and SULLIVAN, T. (1955):Squamous Carcinoma Arising in Previously BenignCystic Teratoma, Obstet. and Gynec., 6, 93.
GALLICO, E. (1947): Le Agglutinine e Figore nelSiero dei ancerosi, Tumori., 21, 189.
KOUCKY, J. D. (1925): Ovarian Dermoids: a Studyof One ,Hundred Consecutive Cases, Ann. Surg.,81, 821.
MASSON, J. C., and OCHSENHIRT, N. C. (1929):Squamous Cell Carcinoma Arising in a DermoidCyst of the IOvary: Report of Three Cases, Surg.Gynec. Obstet., 48, 702.
NOVAK, E. (1958): Textbook of Gynaecologic andObstetric Pathology. 3rd Edition. Philadelphia:Saunders.
PETERSON, W. F. (1957): Malignant Degeneration ofBenign Cystic Teratomas of the Ovary: a iCollectiveReview of the Literature, Obstet. Gynec. Surv., 12,793.
STRATTON, F. (1943): Some Observations on Auto-haemagglutination, Lancet, i, 6,13.
WIENER, S. (1915): A Study of the Complications ofOvarian Tumors, Amer. J. Obstet. Dis. Wor., 72,209.
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