SOLID TUMORS OF THE OVARY.
Solid tumors of the ovary are of rare occurrence. They are said to be found in about 5 per cent. of all the cases of ovarian tumors that are submitted to operation.
The solid tumors of the ovary are fibromata, myomata, sarcomata, carcinomata, and papillomata.
Fibromata.—Ovarian fibromata are very rare; they are histologically similar to fibroid tumors of other parts of the body. They do not form circumscribed new growths, but affect the whole organ, which becomes uniformly hypertrophied, preserving its general shape and anatomical relations. The tumor may contain, between the bundles of fibrous tissue, small cavities filled with fluid. The growth is usually intra-peritoneal and has a well-formed pedicle; it may, however, in exceptional cases be extra-peritoneal and develop between the layers of the broad ligament. In such a case there is difficulty in determining whether the fibroid originated in the uterus or in the ovary. Ovarian fibromata are usually of small size and slow growth. A case has been reported in which the tumor weighed over 7 pounds.
Corpora Fibrosa.—A variety of the ovarian fibromata are the corpora fibrosa, which are due to fibroid degeneration of the corpus luteum. They are tough, fibrous bodies, about the size of a pea, which are occasionally found upon the surface of the ovary. It is said that they may attain the size of a child’s head. They are usually, however, very small, and have no clinical significance.
Myomata.—Ovarian myomata are composed chiefly of unstriped muscular fiber. They are somewhat more frequent than the pure fibromata. The two growths may be mixed, forming a fibro-myomatous tumor. The myomatous tumor may attain the weight of fifteen pounds.
Sarcomata.—The majority of solid tumors of the ovary are sarcomatous in character, and it seems probable that many tumors that are classed as fibroids or fibro-myomata are in reality ovarian sarcomata. The growth may be either of the spindle-cell or the round-cell variety. Occasionally it is an endothelioma, a form of sarcoma developing from the endothelial cells of the blood- and lymph-vessels.
Sarcoma of the ovary differs from sarcoma in other parts of the body in the fact that it is very often bilateral. Sutton states that both ovaries are affected in about 20 per cent. of the cases. Other observers state that ovarian sarcomata are usually bilateral.
The surface of the tumor is smooth, and the general form and anatomical relations of the ovary are unaltered. Ovarian sarcomata are usually of median size, though they may attain enormous proportions and fill the abdominal cavity.
The tumor is usually of rapid growth; in one case it attained a weight of ten pounds within a period of six months. The growth is accelerated by pregnancy. Ascites is commonly present with ovarian sarcoma, and cachexia may appear rapidly.
Ascites caused by peritoneal irritation may accompany any of the solid tumors of the ovary, as other kinds of freely movable abdominal tumor. It is, however, especially characteristic of the ovarian sarcomata, and is a point of diagnostic importance.
Ovarian sarcomata differ from the fibroid and the myomatous tumors in rapidity of growth, involvement of both ovaries, and the presence of ascites. Ovarian sarcomata may occur at any age. They are relatively very frequent in children. An analysis of 60 cases of ovarian tumors in children collected by Sutton shows that sarcomata occurred 16 times.
The symptoms caused by ovarian fibromata, myomata, and sarcoma are those referable to pressure and peritoneal irritation. These tumors, on account of their moderate size and great mobility, seem to be especially liable to torsion of the pedicle. They should be removed by celiotomy as soon as recognized.
Both ovaries should always be carefully examined, for in sarcoma the disease is often bilateral.
Carcinomata.—Primary cancer of the ovaries is very rare. Secondary infection of these organs is, however, of not infrequent occurrence. It is found in cases of cancer of the breast and of the uterus. In 29 cases of death from cancer of the breast, both ovaries were found to be involved in 3 cases.
Primary cancer of the ovary appears as a solid or a cystic tumor. The solid carcinomata are diffuse infiltrations of the ovarian tissue, forming pedunculated, rarely intraligamentous, ovoid or globular tumors having a smooth or slightly irregular surface. They are either of the medullary or scirrhous type. The medullary form is of rapid growth, and may reach the size of the adult head. The scirrhous form is of comparatively slow growth and smaller size, and in consistency resembles a fibroma.
The cystic carcinomata are similar in form to the multilocular glandular cysts, but are smaller, rarely reaching a greater size than that of the adult head. They are adeno-carcinomata or papillary adeno-carcinomata. The surface of the tumor, its walls, and the septa contain to a greater or less extent solid nodules or plates of various size composed of carcinomatous tissue. The nodules often have a papillary character.
Ovarian carcinoma is usually a bilateral growth. Unlike carcinoma in other parts of the body, it may, particularly the medullary form, occur in childhood. It is usually found between the ages of thirty and sixty years. Ascites is commonly present in cancer of the ovaries, the fluid being often tinged with blood; as the disease develops, edema of the lower limbs and cachexia appear.
Cancer of the ovary is an extremely malignant growth, quickly extending to surrounding structures as implantations on the peritoneum, and by metastasis to distant organs. In more than 75 per cent. of the cases operated upon the disease has returned and terminated in death within the first year.
When cancer of the ovaries is secondary to cancer elsewhere than in the uterus, operation offers no prospect of cure. If the disease is secondary to cancer of the uterus, it may be possible to remove all of the affected structures.
Ovarian Papillomata.—Superficial papillomata of the ovary are of very rare occurrence. In many of the cases in which the papillomata appear to grow from the surface of the ovary there had previously been a papillomatous cyst of paroöphoritic origin, which had become perforated and perhaps inverted, so that, after the cyst had become destroyed, the growths appeared to spring from the ovarian surface. Careful dissection and search for the remains of the old cyst should always be made in such cases.
In superficial papilloma of the ovary the growths are in all respects similar to those found in the interior of papillomatous cysts. They may be isolated upon the surface of the ovary, or they may cover it so completely that the ovary is hidden from view. A section, however, will reveal the ovary lying in the centre of the growth.
The papillomata may be pedunculated or sessile. They vary in size. In some cases they form a mass larger than the adult fist.
The disease is often bilateral. Secondary involvement of the peritoneum occurs, as in the case of papillomatous cyst. The course of the disease is similar to that of a perforated papillomatous cyst. The treatment is immediate celiotomy and removal. As in the case of papillomatous cysts, involvement of the peritoneum is no contraindication to operation.
Tuberculosis of the Ovary.—Tuberculosis of the ovary is usually secondary to tuberculosis of the Fallopian tubes. In tuberculosis of the peritoneum the ovaries are often found to be involved, in some cases without accompanying disease of the tube. In phthisical women the ovaries have been found, in rare instances, to be the only portion of the genital apparatus in which secondary deposit of tubercles took place.
Williams states that primary tuberculosis of the ovaries has not yet been described.
The surface of the ovary may be covered with miliary tubercles, or they may be scattered through the substance of the gland. In other cases the ovary contains cavities filled with cheesy material or pus, forming a tuberculous abscess.
There are no characteristic symptoms of tuberculosis of the ovaries. The condition is usually found at operation or at autopsy, associated with tuberculosis of the peritoneum or of some other part of the genital organs, as the Fallopian tubes and the uterus.
The treatment consists in oöphorectomy, unless operation is contraindicated on account of extensive involvement of other structures.
Tumors of the Ovarian ligament.—Fibroid and sarcomatous tumors have occasionally been found in the ovarian ligament. Doran has reported a fibroid of the ovarian ligament that weighed 17 pounds. The writer has removed a sarcoma of the ovarian ligament that weighed 5 pounds.
It is impossible to distinguish these tumors from similar growths of the ovary. They demand like treatment.