Translation by
Dr. Franz Glasauer
Emeritus Professor of Neurosurgery
State University of New York at Buffalo
Buffalo, NY, USA
New Growth of Uterine Glands in Sarcomas of the Uterus and Ovaries
By
Reg.-Rath. Prof. Dr. C. Rokitansky
Among connective tissue tumors affecting the uterus are those containing glandular tubules such as uterine glands. If these tubules are a new growth, then among others they are a Sarcoma adenoides uterinum . As all new glandular growth first appears in the original gland or in its vicinity in the uterus, so it may also be found in the ovaries. This observation of growth was suggested in my earlier description in a tumor of the liver consisting of newly formed liver tissue (Wiener allg. Med. Ztg., April 1859, #14). The degeneration of these glandular tubules to cysts confirm the existence of a Cystosarcoma adenoides uterinum.
Of the existing connective tissue tumors of the uterus, the round fibroids are to be differentiated from the so-called fibrous polyps of the uterus in which glandular tubules are found. These are connective tissue tumors rooted in the basal stroma of the uterus and cannot be shelled out (Paget’s continuous growth) in contrast to the well-circumscribed fibrous tumors. They commonly develop within or from the submucosal stratum and grow into the uterine cavity as so-called polyps of various shapes (cylindric-, pear-, or club-shaped) and are covered by an adherent uterine mucosa. The various changes in its texture may appear identical to the changes seen as a result of chronic inflammation. In contrast to the easily removable fibrous tumors, we commonly consider these connective tissue tumors as sarcoma , here specifically as uterus sarcoma. These tumors growing into a mucosal cavity generally retain their old name of polyp and uterus polyp and, according to the discussion above, would be distinguished from the round fibroids prolapsed into the uterine cavity. As round fibroids may develop within the inner tissue layers of the uterus, so can sarcomas on rare occasion develop from a mucosal-free outer layer.
In view of the above discussion, it is important to recognize the changes occurring in the mucosa and the submucosal stratum of the uterus as a consequence of chronic inflammation. Emphasis is on the findings of elongation of normal uterine glands versus new growth of the glands. Therefore, before presenting cases of glands – containing uterus – and ovarian sarcoma, it is advisable to consider the underlying causes of uterus sarcoma (polyp) and those of chronic inflammation. These changes are as follows:
1.
A smooth mucosa or in places a predominantly bunched section with spongy stringy, areolar (decidua-type), at times also of granulated, papillary appearance is caused by the exuberant growth between the elongated and enlarged uterine glands.
2.
Circumscribed hypertrophy of the mucosa and its glands.
(a)
The mucosa hypertrophies in one or more circumscribed places accompanied by elongation of glands producing the bulge (ref.: H. Mueller: Verhandl. D. phys. Med. Gesellschaft in Würzburg, 4. 1854). This bulge eventually protrudes above the neck and promptly prolapses sometimes on a stalk, into the uterine cavity. In these polypous pouches – mucous polyp of the uterus – frequently, the elongated glandular tubules partly desiccate. In these isolated sections millet- or pea-sized cysts develop, containing a single or layered colloid ball of gelatin-type mucus. This structure then consists of an aggregate of round and facetted cysts which are deposited in scaffolding areas of nuclei rich connective tissue. They represent the so-called Cell - or Vesiclepolyp. The larger superficial cysts intermittently dehisce and are replaced by adjacent ones.
(b)
On rare occasions the elongation of the uterine glands extend in both directions, toward the uterine cavity as well as into the parenchyma. In this case the incumbent bulge acts as a plug of parallel fibers driven into the uterus. Such a picture was encountered in the thick walled uterus of an older woman. Below the left tubal opening was a club-shaped, smooth polyp, about 1′ 2′″ long, with a 1 1/2″ diameter in the neck, and enlarging to 4–5′″ at the free end. A cut through the entire mass showed that the neck penetrated in a wedge-shaped fashion into the uterus to a depth of 4″. The cut surface appears as thready-fibers in its entire length and can be unraveled in that direction. This arrangement is provided by extremely long glandular tubules kept together by nuclei rich connective tissue.
3.
Circumscribed hypertrophy of the submucosa of the uterus to connective tissue pouches – sarcomas – gradually give rise to the fibrous polyps. Inside, one frequently finds parts of intruding, elongated uterine glands or newly formed glandular tubules which degenerate into cysts and thus represent the structures under discussion.
4.
Sometimes uterine mucosa degenerates into a notable thick, rigid, indurated connective tissue stratum containing more or less compact nuclei and fibrous strands in which the glands perished. Frequently it is interspersed by small mucous, or colloid, cysts caused by separated sections of the glands. The peripherally located cysts for the greater part have already burst.
5.
In places, adhesions of the uterine walls are caused by connective tissue arising from the mucosa, rich in nuclei and striped fibers. This especially occurs in the presence of polypous mucosal pouches, vesicular polyps, and small and larger sarcomas (fibrous polyps). At times the uterine cavity is obliterated or invaded by large, already adherent sarcomas.
Following these remarks, I now turn to the description of examined cases. There are three extirpated uterine polyps which were sent to me from an Obstetrical Clinic. The specimens had been preserved for some time in wine-spirits. The fourth case is that of an ovarian cystosarcoma obtained by autopsy.
(a)
A large uterine polyp , 3 1/2–6″″ in diameter with a smooth and bulbous surface. With the exception of a notable thick neck portion, the free surface is covered with a thin, fine stringy and grainy appearing layer with adherent white drusen of fat crystals. The uterine mucosa, which is inverted into the uterine cavity, consists of a thin stroma of nuclei rich connective tissue of an areolar structure without a trace of tubular glands, except for a few areoli in the depth. Adjacent to this layer is the densely interwoven mass of the sarcoma. This consists of an inert, fibrous stroma interspersed by elongated nuclei. The stroma is arranged in bundles of various sizes which crisscross in different directions. In places, the stroma is less compact and spongy. In the lower wall there appears within the tumor mass, a dense nodule, the size of a goose-egg, but located so that it can be shelled out. For the most part, its surface adheres to the wall of a cavity by threads and is in only one place continuous with the tumor mass. In addition, especially within circumscribed areas one notes many cyst-like spaces, from poppy-seed to bean sized, without epithelium but with either smooth or delicate stringy inner linings. Some of these clefts are confluent and some are clustered into groups of 2–3 and are separated by delicate perforated membranes. A section of the tumor from the deep layers is scattered with small spaces and microscopically reveals a collection of rigid connective tissue bundles crisscrossing in different directions. These contain smaller or larger, round or oblong clefts which, except for a barely visible hyaline rim, show no other lining. However, there are spaces that are filled with atrophied cells – an epithelial layer – and on cross section appear to represent tubular structures.
(b)
A lobulated uterine polyp the size of a child’s head. The polyp is covered by uterine mucosa, with the exception of its neck, and preens areas of a discolored, friable, spongy, stringy layer. This layer extends into the depth as a spongy, succulent layer of 3–5′″ thickness and is perforated by numerous clefts of varying sizes (needle-point to millet size). Further into the depth the tissue becomes more fibrous and is scattered with millet size to larger size lumps. Everywhere there are, sometimes in nests, from small, barely visible to larger, round or irregular clefts with smooth or stringy inner walls.
The external layer appears as a horizontally removed segment, perforated by variable sized round or distorted spaces. This segment consists of nuclei rich connective tissue and in places is disintegrated into an opaque detritus.
Layers taken from the succulent, spongy stroma present as a thin or thick meshwork structure of the same nuclei rich connective tissue, containing round or oblong spaces of various sizes. In addition to these spaces, finally there are tubular structures lined with epithelial cells. Evidently, the former are cross – or oblique – sections of the latter.
In addition to the epithelial line spaces, one observes here and in the deep, porous sections of tumor clefts invaded by conical- or club-shaped excrescences, which deform them to lacunar shapes. Adjacent to the clefts and especially in the excrescencies, the tissue consists of streaky, nuclei rich connective tissue; otherwise it is a thread-like connective tissue with crisscrossing fiber bundles and notable areas which look like inserted cut fiber balls.
(c)
A third case of a goose egg–sized uterine polyp is identical to the one described in (a).
(d)
An Ovarian – Cystosarcoma. The autopsy performed on March 2, 1859 on a 68-years-old, malnourished female yielded the following: the body is small and thin, both lungs for the most part are adherent, in the right upper lobe there is a walnut-sized cavity with extensive, indurated desiccation of the tissue and an incorporated yellow, cheesy nodule. In the lung there are numerous thickened, airless areas infiltrated by tenacious, yellow–brownish pus. The ventricles of the heart contain loose fibrin clots. The liver is enlarged and fatty, the spleen is small, the stomach, bowels, and kidneys are pale; in the capsule of the left kidney there is a white fibroid node and the bladder is empty. A small, retroflexed uterus is situated in the left recto-vaginal space whereas its fundus is wedged between the cervix and the left ovarian tumor. The latter is degenerated to a fist-sized tumor, the right half presents as a dense, fibrous mass, whereas the left half consists of an aggregate of serous cysts. The largest of the cysts partially protruded into a cavity of the fibrous mass. The remaining small cysts were adherent to the rest of the surface. The entire tumor was twisted by its sheltered position so that the cystic portion pointed to the right. The tube was somewhat stretched over the tumor and fixed to it up to its fimbriated end. The right ovary was dense, atrophied, and contained a bean-sized cyst which protruded through the surface. Closer examination of the fibrous part of the tumor disclosed on cross section, especially around the cysts, a glandular appearance with scattered, delicate vesicles and grainy nodules. In addition, it contained individual mucous containing cysts of millet to hemp corn size. The microscopic examination revealed numerous tubular, epithelial lined structures within a thick, connective tissue layer. On cross section of these tubular structures, individual slit-like, lacunar clefts were evident into which papillary excrescences of connective tissue intruded.
The conclusions drawn from these observations are:
1.
Among the fibrous uterine polyps are some that contain glandular tubules.
2.
These tubules represent elongated glands of the uterine mucosa, isolated sections of them, or new growth. The latter transform the sarcoma to an adenoides uterinum.
3.
Above all, as new growths are considered (1) large polyps in the depth and (2) those found in great distance from similarly lined uterine mucosa. That such a new growth actually takes place becomes less doubtful, as one may also observe tubular structures very similar to uterine glands in ovarian sarcoma.
4.
In the cell-polyp of the uterus these tubules degenerate to cysts in the same manner as do isolated sections of uterine glands in the desiccated uterine mucosa – Cystosarcoma adenoides uterinum.
5.
Sarcoma tissue in the form of papillary excrescences grow into the space of the cyst-like, degenerated tubules. The slit-like, lacunar clefts scattered within the sarcoma produce on cross section a granular appearance. The circumscribed nodes, which can be shelled out, and appear incorporated in the sarcoma mass doubtless originate from the filling of the greater cyst spaces by intruding tumor tissue – a common appearance, which is especially pronounced in cystosarcoma adenoides mammarium.
6.
A sarcoma, containing uterine glandular tubules, is also found in the ovaries and some cystic structures of the ovaries, therefore become a cystosarcoma adenoides uterinum.
7.
The ones in question and the mucosa lined uterine polyps as a whole undergo changes in their texture which similarly occur in the uterine mucosa in the course or as the end result of chronic inflammation. In the first case described, the uterine mucosa is a stroma of areolar structure in which, except for a few deeper areoli, no tubular glands are present. In the second case, the mucosa is a large, spongy layer similar to the stratum of cell polyps. On a simple, fist-sized uterine polyp without glands (I examined the specimen fresh!), the mucosal lining presents a spongy, very fine, stringy layer, in which especially above and in proximity to the stalk numerous poppy- to millet-sized cysts are present which are frequently confluent and contain clear, tenacious mucus. On microscopic examination the mucosa appears to be a porous, nuclei rich membrane and its pores are encircled by a corresponding vascular mesh which frequently produces papillary, elevated loops. In the depth one finds numerous, epithelial lined, round vesicles – isolated sections of desiccated tubular glands. It is lined by epithelium consisting of pavement – and low cylindrical – cells.