CYSTIC TUMORS OF THE OVARY.
The histogenesis of cystic tumors of the ovary is not yet definitely settled. Every structure that enters into the composition of the ovary has been supposed to form the starting-point of these tumors. There are many classifications of ovarian cysts based upon the clinical, structural, or genetic features. The classification given here seems to me to be the best we have at present for the practical physician.
Fig. 164.—Diagram representing the cyst-regions of the ovary and broad ligament.
Cystic tumors of the ovary may be divided into two general classes:
I. Oöphoritic cysts, which originate from the oöphoron, or the egg-bearing portion of the ovary.
II. Paroöphoritic cysts, which originate in the paroöphoron.
OÖPHORITIC CYSTS.
Cysts of the oöphoron may be subdivided into (a) Follicular cysts; (b) Glandular cysts; (c) Dermoid cysts.
Follicular Cysts.—Follicular cysts originate in the ovarian follicles. If anything occurs to prevent the physiological rupture of a mature ovarian follicle, a follicular cyst may be started. Such cysts begin as retention-cysts of the ovarian follicles.
The condition is usually the result of chronic inflammation. The formation of new connective tissue in the ovarian stroma, the thickening of the tunica albuginea, the presence of inflammatory exudate upon the surface of the ovary, may all prevent the rupture of the follicles. In addition, the inflammatory congestion of the walls of the follicle produces an increased exudation into the ovisac.
Fig. 165.—Follicular cyst of the ovary.
It seems probable that such inflammatory action may also produce cystic distention in the immature follicles that are situated remote from the surface of the ovary.
Follicular cysts may occur at any age, though they are most common during the period of sexual activity. The follicular cysts may occur in one or in both ovaries; usually both ovaries are affected.
Only one follicle may be involved, or a large number of follicles, in different degrees of cystic distention, may be found scattered throughout the ovary.
Frequently one follicle enlarged to the size of a hen’s egg is observed projecting from the surface of the ovary. Sometimes the intervening septa atrophy, and one large cavity is formed by the union of two or more cystic follicles.
Follicular cysts of the ovary do not increase indefinitely with age. They are limited in growth, and in this respect differ essentially from the glandular oöphoritic cysts. They are usually about the size of a hen’s egg. They rarely attain a size greater than that of the adult fist. Exceptional cases have been reported in which the ovarian tumor was the size of the adult head. The tumor may be composed of one chief cyst-cavity, while the rest of the ovary may present a much less marked degree of cystic distention; or a large number of follicles may be uniformly distended each to the size of a cherry, forming an ovarian tumor as large as a child’s head.
When the ovarian follicle becomes distended the walls usually increase in thickness and strength.
The interior of the cyst is smooth. The character of the lining membrane varies with the size of the cavity. In small cysts it is the membrana granulosa—columnar epithelium. In cysts of medium size the cavity is lined with stratified epithelium. In the largest cavities there may be no epithelium present, the lining membrane being fibrous tissue.
The follicular cyst is usually filled with clear serum having a specific gravity of 1005 to 1020. It resembles normal liquor folliculi. The fluid may be purulent as a result of septic infection, or it may be brown or black from the presence of altered blood. Ova are sometimes found in follicular cysts of moderate size. Sometimes hemorrhage takes place into the follicular cyst, forming a follicular blood-cyst, which may attain the size of a man’s fist.
Cyst of the Corpus Luteum.—A variety of the follicular cyst is the cyst of the corpus luteum. Such a cyst is formed by the degeneration and cystic distention of a corpus luteum. These cysts are usually of small size, rarely exceeding that of a walnut. The walls are thick and of a characteristic light-yellow color. The cavity is lined by a delicate membrane. Cysts of the corpus luteum are rare in the human female, but are very common in some of the lower animals—the cow and the mare.
Fig. 166.—Cyst of the corpus luteum, showing the yellow lining membrane (a); b, small follicular cyst.
The symptoms caused by follicular cysts are those of pressure and ovarian pain. The cyst may become impacted and adherent in the pelvis, and may cause pressure. The ovarian pain is analogous to that described under Chronic Oöphoritis. The pain that accompanies this form of cystic tumor of the ovary is much more marked than in the case of the larger kinds of ovarian cyst, which may be unattended by any ovarian pain whatever. In some cases follicular cystic disease of the ovaries is accompanied by menorrhagia or metrorrhagia which is only relieved by oöphorectomy. This symptom, however, is not usual.
The diagnosis of the condition is made by bimanual examination and by observation of the clinical course of the disease. The cystic disease is very often bilateral. The ovarian enlargement is slow in development and is always limited. A moderate maximum size is reached and may persist for years.
Treatment.—The only curative treatment of follicular cystic disease of the ovaries is by operation and removal of the tumor. Operation is required only in those cases in which the suffering is great. The mere presence of the cystic ovary does not demand operation, whether it causes physical suffering or not, as in the case of the cystic tumors hereafter to be considered. It must be remembered, however, that it is often difficult or impossible to make a differential diagnosis between follicular cyst of the ovary and a young glandular or papillomatous cyst, and it is very much safer in all doubtful cases to adopt the operative rather than the expectant plan of treatment. If, after the abdomen is opened, the cyst is found to be follicular, the ovary need not necessarily be removed.
If, at the time of operation, the ovary is found to present but one follicular cystic cavity, this may be opened and evacuated and part of the wall may be excised. If bleeding occurs from the edges of the cyst-wall, it may be controlled by whipping with a fine continuous suture of silk or catgut. Some operators avoid this bleeding by opening the cyst with the cautery-knife. In any case the bleeding is usually slight if a thin portion of the cyst-wall is selected for the incision. If the ovary is filled with a number of cystic cavities, it is safest to remove the whole organ. If the woman be young and anxious for children, the portion of the ovary that contains the cysts may be excised and the wound in the ovary closed by sutures of fine catgut. Simple puncture of the cysts does no good. The conservative operation is especially desirable in case both ovaries are diseased. When but one is affected, the surgeon need not hesitate so much before performing oöphorectomy.
If, as is very often the case in cystic disease of this character, the Fallopian tubes are found closed by inflammatory adhesions, salpingo-oöphorectomy is usually indicated.
Glandular Cysts.—Glandular cysts are also called multilocular ovarian cysts or ovarian adenomata.
It was formerly thought that all ovarian cysts originated in the Graafian follicles. This view has now been given up by most pathologists. The follicular cysts that have just been described never attain a large size, and run a distinctly different course from the glandular cysts now under consideration.
The glandular cysts probably originate from the tubes of Pflüger. It will be remembered that in the embryo the ovary contains many epithelial tubules derived from the germinal epithelium that covers the surface of the ovary. These are the tubes of Pflüger. In the process of development they become converted into Graafian follicles. Abnormally they persist, and have been found in the ovary at an advanced age, as late as the seventy-fifth year. In the newborn infant these tubes have been found cystic—the size of a pea. Such cystic degeneration of persistent tubes of Pflüger is the probable origin of glandular cysts of the ovary. According to this view, all such cysts are due to a congenital defect. Some are perhaps formed congenitally, and remain stationary or develop in later life.
The central cells of the tubes of Pflüger soften and become liquefied, and the tube becomes distended into a small pouch lined with primitive glandular epithelium.
The outer surface of a typical glandular cyst of the ovary presents a smooth, glistening, silvery appearance. This appearance is subject to considerable variation according to the character of the cyst-contents, the thickness of the wall, and the inflammatory and necrotic changes that have taken place. Sometimes there are ocher-colored or brownish spots upon the surface.
The surface of the cyst is often lobulated, from the presence of smaller cysts or a collection of secondary cysts in the wall.
The wall of the cyst is composed of fibrous tissue containing elastic and unstriped muscular fibers. Traces of normal ovarian tissue may be discovered in the cyst-wall. Sometimes a corpus luteum is found in the wall of a cyst of large size, showing that ovarian follicles may ripen and rupture, and that conception may take place even though the ovary is grossly diseased.
The thickest portion of the cyst-wall is that in the region of the pedicle. The thinnest portion is usually opposite the peduncular attachment.
By careful dissection the wall may generally be divided into three layers—an external and an internal layer of fibrous structure, and a middle layer of loose connective tissue. This differentiation is best marked in the region of the pedicle. In the thinnest part of the cyst the coats become blended into a thin, homogeneous, fibrous structure.
The outer surface of the cyst is covered with a layer of endothelial cells. This is not a peritoneal investment. It is intimately connected with the outer fibrous coat of the cyst, and cannot be stripped off. In this respect these cysts differ from some hereafter to be described, in which there is a distinct detachable peritoneal covering.
The blood-vessels of the tumor are distinguished throughout the fibrous wall. When three lamellæ are present, the large arteries are found in the middle layer. Lymphatics, often of large size, are also found in the cyst-wall.
The glandular cyst is always, at first, multilocular; the tumor is made up of several cyst-cavities. As the tumor increases in size the pressure causes atrophy of intervening septa, so that two or more cavities are thrown into one, and the number of loculi becomes correspondingly diminished. As the cyst grows, therefore, the tendency is toward the unilocular form. Careful examination of a unilocular glandular cyst will usually reveal the remains of atrophied septa upon the walls.
The epithelial lining of these cysts is usually composed of columnar cells. In cavities of large size the cells are flattened by pressure, and in cavities of the largest size fatty degeneration and atrophy may have taken place, so that the lining cells entirely disappear.
The cavities are often lined with a soft, velvety membrane, microscopically similar to mucous membrane. The columnar epithelium dips below the surface to form complex mucous glands. These glands may become obstructed, and secondary mucous retention-cysts are formed in the walls of the parent cyst. Such a mass of secondary cysts is often seen projecting into the main cyst-cavity or forming a lobulated prominence upon its outer surface.
Follicular cystic degeneration, such as has already been described, may occur in the ovarian tissue of the wall of the glandular cyst, so that a secondary group of small cystic cavities may be formed.
It is thus seen that the structure of an oöphoritic glandular cyst may be very complex. There may be one or more chief cyst-cavities, on the walls of which may be discovered the remains of septa which had formerly subdivided them. Projecting into the cavities may be seen honeycomb-like masses of secondary mucous retention-cysts; while in the walls of the tumor, perhaps rendering the surface lobulated, may be seen minor cyst-cavities formed by beginning glandular cystic degeneration or by simple cystic degeneration of ovarian follicles ([Fig. 167]).
The contents of a glandular cyst vary greatly, not only in different cysts, but in the different cavities of the same cyst. Pseudomucin, a peculiar mucoid substance excreted from the lining gland cells, is a most important constituent of the contents of this cyst, and is almost characteristic.
The fluid may be thin and colorless; it may resemble thick, tenacious mucus; it may be oily or syrupy in consistency; or it may resemble transparent jelly. It may be colorless, yellow, apple-green, or brown or black from the presence of decomposed blood. As a rule, the fluid becomes thinner as the cyst increases in size and age. The change is probably due to the alteration that takes place in the character of the lining membrane under the influence of continuously increasing pressure.
The specific gravity of the fluid varies from 1010 to 1050.
Fig. 167.—An oöphoritic glandular cyst. The section shows the remains of an atrophied septum, a number of follicular cysts in the wall, and to the right a group of mucous retention-cysts.
As glandular cysts of the ovary originate in the free border of the gland, they are in the great majority of cases intra-peritoneal in their growth. They grow into the peritoneal or the abdominal cavity; they do not push aside layers of peritoneum, like the cysts that originate between the folds of the broad ligament, and which are extra-peritoneal in their development.
Very rarely glandular cysts of the ovary have been found that grew between the layers of the broad ligament and were extra-peritoneal in development. It may be that in such cases the ovary itself had occupied an abnormal position.
The shape of the ovary is very early destroyed by a glandular cyst. The ovarian tissue is incorporated with, and is spread throughout the cyst-wall. In small tumors the remains of the hilum may be found at the pedicle. In no case is the body of the ovary discoverable as a distinct structure lying upon the surface of the cyst.
The pedicle of the cyst is composed of the ovarian ligament, the upper portion of the broad ligament, and the Fallopian tube. These structures are all more or less thickened and lengthened as a result of the traction and of the altered nutrition produced by the growing cyst.
The vessels of the pedicle that are derived from the ovarian and uterine arteries are of various size. The arteries rarely exceed the size of the radial artery.
Glandular cysts are of unlimited growth. They increase in size until they destroy the woman by direct pressure. They literally crowd her out of existence.
The size they may attain is determined only by the powers of resistance of the woman and the distensibility of the abdominal walls. Glandular cysts have been removed that weighed 200 pounds.
The shape of the glandular cyst is approximately spherical. It is often distorted by pressure, and portions of the tumor may represent a mould of parts of the pelvic or posterior abdominal walls.
The glandular cyst is usually unilateral. The proportion of cases in which both ovaries are affected seems to be about 4 per cent.
In some cases, when both ovaries are affected, the cysts may become fused, so that a single tumor is formed, attached by two distinct pedicles. Operation in such cases is often very embarrassing.
The glandular cyst is the most common form of ovarian tumor. It may occur at any time of life from childhood to old age. It is most common between the ages of twenty and fifty.
Dermoid Cysts.—A dermoid cyst of the ovary is characterized by the presence of skin and cutaneous appendages. Dermoid cysts are found in various parts of the body, but they occur most frequently in the ovary. Of 188 dermoid cysts reported by Lebert, 129 occurred in the ovary.
Dermoid cysts comprise from 4 to 5 per cent. of all ovarian tumors.
Simple ovarian dermoids are usually of small or moderate size, varying from the size of a hen’s egg to that of the adult head. The cysts rarely contain more than 8 pints of fluid.
Dermoid cysts may become larger by fusion with glandular cysts or as the result of inflammation. Dermoid cysts are usually unilateral; both ovaries are affected in about 20 per cent. of the cases. They are primarily unilocular. Sometimes two or more dermoid cysts spring from the same ovary, and these contemporaneous cysts may become united, and the contiguous walls may atrophy so that the cavities communicate.
Dermoid cysts of the ovary have been found at all ages—in the fetus of eight months and in women over eighty years of age. They are observed most frequently from the fifteenth to the forty-fifth year.
The external appearance of the dermoid cyst differs from that of the glandular cyst. It is dull and often yellowish or brownish in color.
Upon the internal surface of the cyst is found a membrane which looks like skin and which has a similar structure. The skin may cover the whole of the surface of the cavity, or it may be restricted to a small area, and with the underlying tissue form a prominence of the cyst wall—the so-called parenchyma body. This body is composed of tissue derivatives of one, two, or all three layers of the blastoderm from the surface inward—the ectoderm, mesoderm, and entoderm.
The following cutaneous appendages are found: hair, sebaceous glands, sweat-glands, teeth, mammæ, horn, nails. The cyst may also contain bone, unstriped muscle, and tissue resembling brain-matter.
The hair may arise from the whole surface of the cyst, or tufts of various length may be found growing from slight prominences of the surface. The hair is usually short; it is sometimes found, however, varying in length from 4 or 5 inches to 5 feet.
There seems to be no relation between the color of the hair of the dermoid and that upon the external surface of the body of the individual. The hair in an ovarian dermoid of a negress has been found of a blonde color.
The hair changes in color with age, and in an old woman may become white.
The hair is constantly shed, and the cyst may contain a large quantity of short loose hair mixed with the other contents. Sometimes the shed hair is found rolled up in balls of sebaceous matter.
Sebaceous glands and sweat-glands are usually numerous.
Teeth may be found free in the cyst-cavity, or they may be attached to bone or cartilage within the cyst-wall, while the crowns project into the cavity; or they may lie completely imbedded in the wall. They are often well formed, though they may be faulty in development and shape. They are usually few in number, ranging from one to ten. Many more teeth than this, however, are sometimes found; in one case there were 300.
Mammæ are found in various degrees of development. In some cases there are present one or more tags of skin resembling a nipple. In others the mammæ may be well formed and may contain glandular tissue.
The bones appear as delicate laminæ or spiculæ in the cyst-wall. They often present a striking resemblance to the flat bones of the skull and the jaw-bones.
The contents of a dermoid cyst vary in consistency. All the substances discharged from the lining membrane enter into their composition. They may consist of a thick oily fluid of a yellowish or brown color, or a pultaceous, semi-solid mass. They resemble the contents of a wen or a sebaceous cyst. They are usually filled with loose hairs and exfoliated epithelium. Though the fatty contents may be in a fluid condition during life, yet they solidify when exposed to the air and after death.
In some cases a dermoid cyst has been found in one ovary while a glandular cyst was in the other. Again, a single ovary may be the seat of a mixed tumor composed of dermoid and glandular cysts. In most of such cases the dermoid forms a single loculus of the tumor. Sometimes the septum between the dermoid cavity and the glandular cystic cavity atrophies and the two cavities are thrown into one. Such an occurrence explains those cases in which the cavity of a multilocular cyst is found to be partly lined with skin which is continuous with the cylindrical epithelium characteristic of the glandular cyst.
The sebaceous glands and the sweat-glands in the walls of an ovarian dermoid may become obstructed and undergo cystic degeneration, forming in this way groups of secondary cysts.
Dermoid cysts of the ovary are usually intra-peritoneal in their growth, like the glandular cysts. In some cases, however, they develop between the layers of the broad ligament, and may assume any of the positions characteristic of such extra-peritoneal growths.
Teratoma, a very rare form of ovarian tumor, is an atypical modification of the dermoid, the teratoma bearing a relation to the dermoid similar to that of carcinoma to adenoma. While in the dermoid the chief mass of the tumor has a cystic character, the cystic cavity containing the secretions from the lining epidermal tissue, the teratoma is for the most part a solid tumor, and the productive activity of the tissue is a cellular hyperplasia.
They appear as pedunculated nodular tumors, with a smooth surface, usually reaching a large or enormous size. The substance of the tumor is composed of the dermoid tissue spoken of, formed into irregular masses of various size, form, color, and consistency, separated by connective-tissue fasciculæ and infiltrated with small and minute cysts (dilated glands or degenerated areas). The tumor is characterized by an atypical arrangement, form, and structure of the epithelium (after the type of a carcinoma) and an excessive growth of embryonal connective tissue (after the type of a sarcoma). It is extremely malignant, being destructive and distributed by metastasis and implantation.
The cause of dermoid tumors of the ovary is unknown. Several different theories have been advanced, no one of which seems to be generally acceptable.
PAROÖPHORITIC CYSTS, OR PAPILLOMATOUS OVARIAN CYSTS.
There is an interesting variety of ovarian cysts which is characterized by the presence of papillomata, or warts, upon the inner surface. These cysts arise from the paroöphoron or from the hilum of the ovary. Many theories have been advanced to explain the origin of these tumors. Pathologists are far from agreeing upon this subject. Perhaps the most popular view among English and American pathologists is that the papillomatous cysts originate from the remains of the Wolffian body which may persist in the paroöphoron in various stages of degeneration.
As paroöphoritic cysts spring from the hilum or the attached portion of the ovary, and develop in the direction of least resistance, they very often separate the lamellæ of the mesovarium and invade the loose connective tissue between the layers of the broad ligament. These cysts are thus very often extra-peritoneal or intra-ligamentous in their development.
Some writers of experience state that three-fourths of all papillomatous tumors of the ovary are of intra-ligamentous growth. This has not been the experience of the author. The majority of the papillomatous ovarian cysts that he has seen have been intra-peritoneal in development, and have had as well-defined pedicles as the ordinary multilocular ovarian cyst.
Fig. 168.—Papillomatous cyst of the paroöphoron. The section shows the papillomatous growths in the interior and the relation of the oöphoron.
Cyst-wall.—If the papillomatous cyst be intra-peritoneal in development, two layers of tissue may be distinguished in its wall: an outer dense layer, composed of laminated connective tissue which sometimes contains unstriped muscle-fibers; and an inner loose layer of fibrous tissue. Both layers contain numerous blood-vessels.
If the cyst be extra-peritoneal or intra-ligamentous in its development, we find, in addition to the two layers just described, an outer coat of peritoneum which is derived from the broad ligament.
The internal surface of the cyst—the walls and the papillæ—is covered by a single layer of cylindrical epithelial cells, which may become flattened by pressure in the large cysts. The epithelium is often ciliated.
Upon the interior of the papillomatous cyst are found warts or papillary growths. These growths vary in size from that of a grain of sand to that of the fetal head. They may be scattered over the cyst-wall or collected in groups. The larger growths often form arborescent, cauliflower-like masses, which may be so numerous and luxuriant that rupture of the cyst results.
In color the papillomata vary from whitish to dark red or black, according to the vascular supply. They are sometimes yellow as the result of fatty degeneration. They are usually very vascular, and bleed freely when manipulated.
The papillomata may be sessile or pedunculated. The pedicle is sometimes very long and thin. Calcification of the papillomata often takes place.
Papillary cysts are usually unilocular. In any case the number of secondary loculi is much smaller than in the glandular cyst.
Fluid Contents.—The fluid contents of the papillomatous cyst differ considerably from those of the glandular cyst of the ovary.
In the papillomatous tumor the contents are usually clear and of a watery consistency, with a specific gravity of from 1005 to 1040. They are not often thick, mucous, or gelatinous in consistency, as in the glandular cyst. The color varies from light yellow to dark brown from admixture of blood. As in all cystic tumors, the character of the contents depends upon the accidents that have happened during the growth of the cyst.
Papillomatous cysts are more often bilateral than any other cystic tumors of the ovary. They affect both ovaries in from 50 to 75 per cent. of the cases. For this reason the operator should always carefully examine the second ovary after removing an ovarian cyst, for beginning cystic degeneration may be found in it also.
Papillary cysts are usually of smaller size and of slower growth than glandular cysts. The papillomata usually perforate the cyst and invade the peritoneum before large size has been attained. These tumors, therefore, are not often seen of larger size than the adult head.
Though papillomatous cysts of the ovary are not as common as the glandular cystomata, yet they are by no means unusual. The statistics of operators vary a great deal. In 600 ovariotomies Schroeder found 50 papillomatous cysts—somewhat over 8 per cent. In the experience of the writer they have been very much more frequent than this.
The papillomatous cyst is the most dangerous cyst affecting the ovary. The danger lies in metastasis of the papillomatous growths to the general peritoneum. Metastasis occurs from the perforation of the cyst-wall and the escape into the peritoneum of the papillomatous masses.
The tendency to rupture of the cyst-wall is one of the characteristics of this form of tumor. The wall becomes weakened by atrophy or fatty degeneration, or by direct pressure of the luxuriant papillary growths. These growths make their way to the outer surface of the cyst, and extend thence throughout the peritoneum; or, if rupture takes place, the cyst may become so inverted that the site of each ovary is occupied by a mass of papillomata; the formerly enclosing cyst has disappeared, and its remains can be discovered only by careful dissection ([Fig. 169]). Such a condition has undoubtedly often been mistaken for primary papilloma of the ovary, the real origin in a papillomatous cyst not having been detected.
The secondary affection of the peritoneum is due not only to continuity of tissue, but to implantation and growth of portions of papillomata that have become broken off and carried to different parts of the peritoneal cavity. Such secondary growths may extend throughout the whole abdomen from the pelvis to the diaphragm, covering any of the viscera. They resemble in all respects the original papillomata found in the interior of the ovarian cyst. They sometimes form cauliflower-like masses as large as the fist, and may be palpated through the abdominal wall. They are very vascular, and bleed profusely on being handled. The smallest particles of papillomata are capable of infecting the peritoneum or other tissues in this way.
Fig. 169.—Double papillomatous cyst of the ovary. The right cyst has ruptured and is turned inside out, showing a mass of papillomata. Papillomata have penetrated the wall of the left cyst. The peritoneum has been infected, and a papillomatous growth appears on the fundus uteri.
The escape of a small quantity of the cyst-fluid into the abdomen during the removal of the tumor may cause subsequent recurrence in the peritoneum. Secondary development of the growth in the abdominal cicatrix, or its appearance in the site of puncture after tapping, is due to the same cause.
Papillomata of the peritoneum are usually accompanied by ascites. This is a prominent symptom in those cases of papillomatous ovarian cyst in which secondary infection of the peritoneum has taken place. In rare cases ascites is present, though perforation of the cyst and involvement of the peritoneum cannot be detected.
Sometimes perforation of the cyst takes place into adjacent organs, especially if the growth be intra-ligamentous. In such cases the papillomatous masses may protrude into the bladder, the rectum, or the cavity of the uterus.