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THE AMERICAN JOURNAL of CANCER a Continuation of the Journal of Cancer Research

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THE AMERICAN JOURNAL of CANCER a Continuation of the Journal of Cancer Research THE AMERICAN JOURNAL OF CANCER A Continuation of The Journal of Cancer Research VOLUMEXVI MAY, 1932 NUMBER3 OVARIAN NEOPLASMS W. BLAIR BELL AND M. M. DATNOW In the first part of this communication l some points in the pathology of ovarian neoplasms were discussed. Here we shall first consider certain aspects of the clinical features associated with them. These cover so large a range of connected phenomena and conditions-namely, the symptoms and physical signs in a variety of circumstances which are related to the size and position, the complications, and the biological nature of the tumour concerned- that it will be neither possible, nor indeed desirable, to present a complete study in this place. Afterwards we shall examine some general principles in regard to the treatment of these neoplasms, especially in relation to the pathological and clinical features pre- sented, and to the age and condition of the patient. I1 CLINICAL FEATURES It is somewhat difficult to collate statistical information on a scale large enough to enable us to draw definite conclusions, even in respect of the average age and parity of the patients affected, for such figures do not seem always to have interested the collectore of 1 This paper, which is a continuation of that published in an earlier number of this JOURNAL(16: 1, 1932), likewise contains the substance (amplified in regard to statistics by M. M. Datnow) of the Introduction by W. Blair Bell to the Discussion on the subject at the British Congress of Obstetrics and Gynaecology held in Glasgow on April 21, 22 and 23, 1931, for an account of which see Journal of Obstetrics and Gynaecology of the British Empire, 38: 279, 1931. 439 440 W. BLAIR BELL AND M. M. DATNOW small numbers of cases. Yet it is only by putting together the findings in various series of small groups that we can obtain suffi- cient material for more comprehensive studies. We have made an attempt to collect from the literature and to tabulate certain features, and the figures given include analyses of some of our own material. We have not been through old hospital records, to which we have access, owing to the irregular manner in which the notes used to be kept, for, although certain figures relating to age would be obtainable, the pathological records are rarely adequate. Table VI relating to malignant tumours gives an analysis of forty-nine of our own recent cases and one museum specimen, of which we have full particulars. PREVIOUSHISTORY For the most part the previous history, unless there be some- thing in it which is outstanding, is rarely recorded. Yet there are many points which would be illuminating had we a sufficient num- ber of cases on which to base our conclusions. For example, in the literature it is rarely possible to discover in the case of primary malignant cystic tumours whether the patient has had the tumour for many years. Among our own patients we have observed in- stances in which tumours had been known to exist for a number of years, and which on removal showed commencing and localized malignant changes in an otherwise innocent neoplasm. Since the supervention of carcinoma in an innocent neoplasm has been re- cently denied (44, 51), the question becomes of considerable im- portance both in respect of diagnosis and treatment. Among 232 cases of cystadenoma investigated by Smith (SO), Fleming (48), and ourselves, in 28-that is, 12 per cent-malignant changes had commenced. In many of these cases-especially in those of cystadenoma- in which changes are stated to have occurred, there is evidence of a more or less symptomless preexisting tumour for many years. In most a history can also be obtained of pain, moderate in severity, which is first occasional and at last almost constant, in the previous painless tumour. If relief be not given, the patient begins to lose weight and usually ascitic fluid accumulates. All these facts can be gleaned from the properly recorded histories of such cases. An example of a case of this kind is the following: S. B., aet. thirty-six years, was a widow and nulliparous. Menstrua- tion was regular 4/28. She had complained of swelling of the abdomen OVARIAN NEOPLASMS 441 for several years. Latterly there had been pain and loss of weight. There was a considerable quantity of ascitic fluid. A diagnosis of bi- lateral malignant disease of the ovaries was made. Spinal anaesthesia was administered and panhysterectomy with bilateral salpingoophorec- tomy was performed (Fig. 57). The patient made a good recovery and has remained well for t'wo years. FI~.57. S. B., AET. THIRTY-SIXYEARS: BILATERAL PSIUDOMUCINOUS CYSTADE- NOMA, IN WHICHTHERE ARE MALIGNANTCHANGES IN THE SOLIDPARTS Histological Examination: For the most part the tumours are innocent in the papillary portion, but here and there evidence is obtained, owing to the manner of epithelial proliferation, that the tumours are becoming malignant. Sections illustrating the earliest changes that occur when the biological nature of an ovarian neoplasm is altering have already been given (Figs. 42 and 46). Innocent Tumours Cystadenomata: In records of 468 cases in which statements regarding age are made, we find that the youngest patient was seventeen years of age and the oldest was seventy-three. In our own cases the average age was 44.5 years; in Miss Fleming's, 42.4 years. Several other authors state that the commonest age is between forty-five and sixty-five. This, however, seems to be above the average, which from Miss Fleming's and our figures com- bined is 43.2 years. 442 W. BLAIR BELL AND M. M. DATNOW Papillary Tumours: Miss Fleming, in a small group, gives the average age as 43.6 years. Erdmann and Spaulding (47), from an analysis of 44 examples give forty-one to fifty as the decade in which the largest number of cases is seen. Cystic Teratomata: In our patients the average age was thirty- seven years, while Miss Fleming gives an average age of 34.5. Smith states that 63.3 per cent of all cases occur between the ages of twenty-four and forty years, a wide distribution period. Fibromata: In our patients the average age was forty-four years. Miss Fleming gives 42.5 years as the average age. Smith states that 58 per cent of these tumours occur in women between the ages of thirty and fifty years. Malignant I'umours Carcinorr~ata(primary and secondary): The average age of our patients was 40.5 years. Miss Fleming's patients were of an aver- age age of 47.1 years. In McIntyre's (49) series the average was forty-four years. In Bride's (45) patients the average was fifty- two years; in Whitehouse's (52) forty-seven years. Smith states that in half of all cases of malignant disease of the ovaries the patients are between the ages of forty and fifty-five years. Sarcomata: Williamson and Barris (53) state that "the greatest number of cases are met with about the age of puberty; the in- cidence is less during sexual life but rises again after the meno- pause." No figures are given. It is difficult to obtain statistics of value, for the lesion is comparatively rare and most observers include lepidomata (endotheliomata) and not tumours arising from connective tissues only. In our own small number of cases the average age was forty-six years. These data bring to light information which should prove of considerable interest if it is verified by studies of larger numbers of cases in the future, and this doubtless will be possible with the better methods of recording now generally practised. The figures here given show that innocent ovarian tumours oc- cur at a higher average age than has usually been thought. Ex- cept in the case of cystic teratomata (dermoids), which would be expected at an earlier age in view of their pathology, the average age of primarily innocent tumours is definitely over forty years, and this average lies in the immediate premenopausal period. In- nocent tumours only infrequently arise after the menopause. OVARIAN NEOPLASMS 443 Malignant neoplasms seem to occur at a somewhat later period, although the average ages quoted are rather lower than those usually described. Putting aside cystic teratomata, it is, moreover, of the greatest interest to observe that for innocent and malignant neoplasms con- sidered together the average ages for all varieties fall within an eight-year period, forty-two to fifty years. We can, therefore, with confidence assert that the involutionary period of reproductive activity is that in which neoplasms are most generally seen, as is the case in respect of malignant diseases elsewhere. The fact that innocent neoplasms of the ovary fall within this period seems an obvious pathological principle in view of the special life history of the organ concerned. Although in this section we have dealt almost entirely with average ages, it must not be forgotten that many cases of all kinds must inevitably fall above and below the figures given; and since the age of the patient is always taken into account, it is those that are outside the average period which often cause difficulties in diagnosis and treatment, as will become evident directly, so it is never wise to lay too much stress on average figures: if good results are to be obtained, each case must be judged on its merits. PARITY Table IV shows the number of cases of each type of innocent tumour considered in relation to parity. TABLEIV Innoce~ttNeopla.sms in relation to Parit?/ I I Type of Ncoplasrn Cystadenonra Papillary I Derrnoid Fibroma Total nunlher of cases una- lyaed * .................
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