CARCINOMATOUS DEGENERATION OF UTERINE MYOMA.
Dr. Le Conte resented a specimen of large in traligamentous fibromyoma of the uterus with endometrial car cinoma of the fundus. The specimen had been removed from a woman, aged thirty-six years, who was admitted to the Pennsyl vania Hospital January zo, i9oo, well nourished, but very anaemic from profuse bleeding from the uterus. A blood count showed red cells, 2,000,000 ; white, 7400 ; marked poikilocytosis, haemo globin, 18 per cent. A large, smooth, firm, movable tumor ex tended from the pelvis to two inches above the umbilicus. Vagi nal examination revealed a normal cervix with a virgin os, which was continuous with the tumor above. The patient was placed at absolute rest, with the most nourishing of diet, ferruginous pills, and i/ioo of a grain of atropia sulphate three times a day. At the end of a week the bleeding had practically ceased. Feb ruary 28, haemoglobin had reached 57 per cent.; March 2, the tumor was removed. It was almost entirely covered by a greatly hypertrophied broad ligament It filled the whole of the pelvis, making it impossible to reach the vessels until the broad ligament had been completely split across. The uterus was amputated at the internal os, the stump closed, and the broad ligaments whipped together with catgut. Dr. Cattell, pathologist to the hospital, reports as follows: The specimen can best be described as composed of two parts, the one a large myofibroma, the other the uterus, with cancerous degeneration of the fundus extending down within three-quarters of an inch of the cut portion. The weight of the mass is four pounds fourteen ounces, the length eight inches, and the width seven and one-half inches. Microscopically, the cancer is of the glandular variety, the acini are long and tortuous, and in places well filled with epithelial cells arranged in layers.
At the time of operation there was nothing to suggest cancer, or a complete hysterectomy would have been done. The point of interest now is whether the stump of the cervix should be removed, or whether an amputation three-quarters of an inch away from diseased endometrium is a sufficient safeguard to the patient. Of all the situations in the body, carcinoma of the fun dus uteri is by far the most favorable, and operation has been followed by the largest proportion of cures. Dr. C. B. Penrose recently told the reporter that he had three times amputated the uterus at the internal os for causes other than cancer, and that an examination of the specimens later revealed carcinoma of the fundal endometrium. In each case he had gone beyond the dis ease for half or three-quarters of an inch, and none of the patients would consent to a second operation. The last patient was oper ated on four years ago, and all are living and well, and free from a return of the disease.
Dr. Beyea said that he remembered very well the three cases operated upon by Dr. Penrose, referred to by Dr. Le Conte, having himself made the microscopical studies of the growths. In all three the malignant disease was in a very early stage of development ; in fact, there was some question of doubt as to the actual presence of such a change. The endometrium showed the microscopical changes characteristic of the diffuse hyper plastic or fungoid endometritis described by Olshausen, but in the deeper portion of the endometrium the glandular proliferation was so great that it seemed to be breaking through into the stroma tissue. They were cases of hyperplastic endometritis in which there was a strong suspicion of beginning malignant adenoma tous change. There was no positive diagnosis of malignant adenoma. They were not adenocarcinoma or medullary car cinoma. For these reasons they can scarcely be of value in considering the danger of leaving the cervix behind when there is carcinoma of the body of the uterus. Carcinomas of the body of the uterus, however, rarely infiltrate into the cervical tissue, but, beginning in the corporeal endometrium, infiltrate and destroy. the muscle wall of the body, and finally break through the peritoneum. In one instance he had observed the muscle tissue of the body quite completely destroyed by the carcinomatous disease, which formed nodules beneath the peri toneum and distorted the shape of the uterus. Even here the cervical tissue was normal. The patient has now been free from recurrence five years. He would say from his experience and microscopical studies of these cases that it is quite im probable that there will be a return in Dr. Le Conte's case. The association of carcinoma with myofibroma of the uterus has not infrequently been reported. He had observed three such cases. Last year he had under his care a woman who had a carcinoma of the cervix with a large multinodular fibroid of the fundus. The case was an inoperable one ; the infiltration extending into the broad ligaments. Another case was that of a woman operated upon some four or five years ago. There was an interstitial fibroid nodule the size of a baseball at the fundus, and an ad vanced malignant adenomatous disease arising in the endometrium and destroying the muscle wall of the uterus. Here, too, the cervix was normal. It was the only typical case he had seen of that form of malignant disease which Ziegler described as ade noma destruens. The gland spaces were irregular, one breaking through into another, and they were lined with a single layer of cylindrical epithelium. Nowhere did the cells fill up a gland space or present the change characteristic of adenocarcinoma. He believed this to be an extremely rare form of carcinoma of the uterus.