Granulosa Cell Tumour with Fibromyoma of Uterus

GRANULOSA CELL TUMOUR WITH FIBROMYOMA OF UTERUS

(Report of A Case)

by NrRMALA SwAMI*, M.D., and s. P. PATANKAR** , M.B., B.S., D.G.O.,

Granulosa cell tumour of the ovary She was well built and fairly nourished. is rather rare, though Novak gives Mucous membranes were pink. Systemic examination was normal. Blood pressure the incidence as 10 per cent of all the 100170 mm. of Hg. solid malignant tm;nours. At S.S.G. Speculum examination showed pin-point Hospital, during the last five years, os. Cervix was flush with the vaginal vault. there were four cases of granulosa On bimanual examination, Cervix was downwards and backwards. Uterus ante cell tumour. Total number of ovarian verted, deviated to the left, normal in size neoplasms was 100, giving an in·· and consistancy, with restricted mobility. cidence of 4% . One case recently There was an irregular mobile mass in the treated is being reported for its in right fornix. Left fornix was found clear. teresting feature of a granulosa cell A provisional diagnosis of granulosa cell tumour was made and patient was admit tumour associated with calcified ted in the ward. fibroid. Investigations Case Report Hb- 9 Gms.%, W.B.C. - 8600/cm. An elderly woman, aged 52 years, came P - 70%, L - 25%, E - 3%, N - 2o/a to O.P.D. on 29-11-62, with the complaints B. T. - 0.50 min. C. T. - 3.45 min. of post-menopausal bleeding for the last 10 Dilatation and curettage was done before months off and on, coming at intervals of laparotomy; the endometrial pattern was in 2-3 days. The bleeding was just spotting the proliferative phase. and would stop by itself. She had burning 1-aparotomy was done on 4-12-62. On micturition for 15 days, much marked at opening the abdomen, a stony hard mass the start of the act of micturition. with rough surface was seen (on the right The patient had menarche at 14 years of side). The uterus was not visualised at all. age, with regular menstruation for 5-6 This hard lump was about 7.5 x 5 x 3 ems. days, moderate in qu::tntity and painless. in size. It was adherent anteriorly to the She attained menopause 12 years back. bladder, and on the sides to the omentum. Patient was a nullipara. Husband expired Bladder was separated and pushed down. 20 years back. After separating the adhesions all round, the mass was found situated at the right * Department of Obstetric and Gynae cornual region of the uterus without any cology, Shree Sayaji General Hospital, pedicle. Right tube could be seen on the postero-inferior aspect of the mass. This Baroda. calcified fibroid was removed and after Received for publication on 26-4-63. removal the uterus was properly seen. On GRANULOSA CELL TUMOUR WITH FIBROMYOMA OF UTERUS the left side there was an ovarian cyst of Patient came with complaint of only 5 x 3.5 x 2 ems. which was adherent poste riorly to the pelvic colon. post-menopausal bleeding; on bima Adhesions were separated and the cyst nual vaginal examination, tumour was removed. A panhysterectomy was done in the usual way. There was a small lemon-size fibroid on the left lateral side of the cervix. It was removed along with the uterus and cervix. Post-operative period was uneventful. She was discharged on thE: eleventh post operative day. Photographs are given at the end of the article which will show the exact relations of the various structures.

Pathologist's Report Slide No. 1. Low power view of granu losa cell tumour, showing tendency of the granulosa cells to form small clusters or Fig. 2 rosettes around a central lumen giving an impression of primordial follicles. Slide No. 2. High power view, showing cystic spaces surrounded by tumour cells. The cells near this cystic space show an arrangement in antipodal fashion. Slide No. 3. High power view showing the fibromyoma. Slide No. 4. Calcified fibromyoma, show ing calcification. Slide No. 5. Uterine endometrial' pat tern, proliferative phase. Discussion: The chief interesting point about this case is association of fibroid with granulosa cell tumour. Fig. 3

Fig. 1. Fig. 4 430 JOURNAL OF .OBSTETRICS AND GYNAECOLOGY OF INDIA

A number of cases are reported in the literature of this type. In the series of Flenberg there was one case of granulosa cell tumour with fibrom yoma. Frachtman also reported gra nulosa cell tumour with enlarged uterus with few calcified fibroids, largest being 5 ems. combined with endometrial carcinoma. Dockerty and MacCarty reported 8 cases of uterine fibroids with granu losa cell tumours in a series of 30 gra nulosa cell tumours. Fig. 5 Nelson and Henderson reported 5 cases of granulosa cell tumour with uterine fibroids in a series of 21 gra nulosa cell tumour. No other series seems to report such a large number of granulosa cell tumours with fibroids. This may lead us to the unsolved problem of etiology of fibroids. Nelson and Anderson say that the p ssibility of association

of oestrogen secreting ovarian neo- 4 plasm and uterine fibroids should be considered but a definite conclusion Fig. 6 of direct relationship is unwarranted. The incidence of granulosa cell tumour is the highest at the age of 50-60 years. In post-menopausal patients, bleeding is the usual symp tom. With increased problems of geriatrics this symptom will have to be given more and more importance, keeping in mind the possibility of estrogen secreting tumours. Schnei der had 31 cases of granulosa cell tumour, out of which 19 were post menopausal and out of these 19 Fig. 7 patients, 12 patients had post-meno pausal bleeding. This shows the im felt on right side was diagnosed as portance of post-menopausal bleed granulosa cell tumour which turned ing. out to be a fibroid and the real granu The size of the tumour is very ___., losa cell tumour was on the left side. variable. A microscopic tumour was

.. GRANULOSA CELL TUMOUR WITH FIBROMYOMA OF UTERUS 431 reported by Nelson and Henderson with granulosa cell tumeurs is dis while the largest reported granulosa cussed. cell tumour is of 24 lbs. The patients with granulosa cell Acknowledgement tumour getting endometrial malig We are very grateful to the Head nancy is a very debatable point. The of the Department, Dr. T. V. Patel incidence varies from 6.1 to 27%. for giving us his valuable guidance. According to Hertig, the incidence We are also thankful to the Professor of endometrial carcinoma in the pre of Pathology for preparation of histo.~ sence of feminising ovarian tumours logical sections of the tumour. Last is 17 times greater than expected in ly, we are thankful to the Dean patients of comparable age. On the S.S.G. Hospital for permitting to contrary Emge found, in '7 53 feminis publish the hospital records. ing tumours, only 25 cases of endo metrial malignancy. He feels strongly References that there is no. relation between 1. Benawri, Sarla: J. Obst. & Gynec. feminising tumours of ovary and India. 12: 733, 1962. endometrial carcinoma. 2. Brock, D. R.: Am. J. Obst. & The chances of the tumour itself Gynec. 83: 109, 1962. being malignant cannot he vouch 3. Dockerty, Cary M., Thompson, safed and it is believed that all gra W. B. (Jr.) and McCall, Milton L.: nulosa cell tumours must be taken as Am. J. Obst. & Gynec. 76: 653, potentially malignant. The reports 1958. vary from 15.4% of Traut to 23.1 o/r 4. Fienberg, Robert: Am. J. Obst. & of Novak. Gynec. 76: 851, 1958. In post-menopausal age abdominal o. Frachtman, K. G.: Am. J. Obst. pan-hysterectomy followed by deep & Gynec. 81: 779, 1961. X-rays is the proper treatment. 6. Francis, H. H.: J. Obst. & Gynee. Br. Emp. 64: 274, 1957. This patient was given deep X-ra.,.s 7. Greenhill's Year Book, 1947-48, l~- and she comes regularly for a follow 463. up. 8 . Harris, Hilda R.: J. Obst. & Gynec. Brit. Emp. 64: 272, 1957. Summary 9. Henderson, D. Nelson: Am. J. ( 1) A case of granulosa cell tumour Obst. & Gynec. 43: 194, 1942. with fibromyoma of uterus has been 10. Novak, Emil and Novak, Edumund: reported. Functioning Tumours of the Ovary. (2) Incidence of granulosa cell 11. Roddick, J. W. (Jr.), Greene, R. R.: tumour during last five years is 4 per Am. J. Obst. & Gynec. 75: 235, cent of 100 ovarian neoplasms. 1958. (3) The associated fibroid at the 12'. Schneider, George T.: Am. J , fundus of the uterus was calcified and Obst. & Gynec. 79: 921, 1960. had no pedicle. 13. Shaw, Wilfred: British Practice of ( 4) Incidence of association of Gynaecology, Chapter XI, revised fibroids and endometrial car9inoma by John Howkins.