Biitish JOlhrnd of Obstetrics and Gynuecology September 1990. Vol 97, pp 855-856
Bilateral squamous cell carcinoma of the ovary. Case report J. M. RADHI, S. M. AWAD
Case report
A 64-year-old multiparous woman presented with vague lower abdominal pain and swelling, associated with constipation and weight loss over 5 months. H e r past medical history included diabetes mellitus, pulmonary tuberculosis and a cerebrovascular accident causing right hemiplcgia and dysphagia. Examination showed features of right hemiplegia and slight conjunctival pallor. There was a hard, irregular pelvic-abdominal mass equivalent in size to ahout 16 weeks gestation. There were no dilated veins. skin metastasis or ascites. Pelvic examination confirmed the presence of a hard, irregular, fixed mass that could not be distinguished from the uterus. The cervix felt normal, but was fixed high behind the symphysis pubis. Invcstigation revealed normocytic anaemia (HI?8-9gidl. MCV 82 fl). Blood chemistry, liver function tests, chext X-ray and intravenous urography were all within normal limits. Ultram i n d showed a normal liver. no ascitcs and an irregular, large mass occupying most of the pelvis. Barium enema showed indentation of the sigmoid colon. After full bowel preparation, laparotomy was undertaken. This revealed an inoperable 'frozen pelvis' with large. fixed. bilateral ovarian turtiDepartment of Patholog!, 'I he Moncton Hospital, Moncton, New Bronswick, hlC 628, Canada I hl RADHI Department of Obstetrics and Gynecology, Charles S. Curti9 Memorial Hospital, St Anthony,
Newfoundland 4 0 K 4S0, Canada S M .4WAD Correspondence J M Radhi. M B , Dcpartment oi Pdthology, I h e Moncton Hospital, Moncton. New Brunswick kIC 6L8, Canadd
ours, metastatic seedlings on the peritoneum, liver and bowel surfaces and enlarged paraortic lymph nodes. 'The transverse. descending and sigmoid colon were adherent to the pelvic tumour and there was marked bowel distension, indicating subacute large bowel obstruction. Omentectomy was carried out and the large bowel was frced from adhesions to the tumour. A diagnosis of Stage IV ovarian carcinoma was made. Histological examination of the omentum showed a metastatic poorly diffcrcntiated, nccrotic, squamous cell carcinoma. Examination of the peritoneal fluid revealed clumps of ncoplastic squamous cells. A course oT chemotherapy was planned but the patient died, due to respiratory failure, 9 days after surgery. Autopsy rcvealed massive pulmonary oedema and recent myocardial ischaemia. The abdominal cavity contained 600 ml of' haemorrhagic fluid. There was a large pelvic mass adherent to the pelvic wall. Careful dissection showed that both ovaries contained lobulated, partly cystic and partly solid tumour with extensive necrosis, measuring about 15 X 10 X 10 cm on the right side cm on the Left side. Both ovarian and 1 3 ~ 1 2 x 8 tumours inliltrated the uterine and bladder walls but the endometrium, cervix and bladder mucosa wcrc normal. Extensive sampling of the ovarian masses showed a necrotic, poorly differentiated, squamous cell carcinoma with individual cell keratinization and small occasional keratin pearls. No evidence of teratoma, Brenner turnour: or endometriosis was seen. The endometrium was atrophic and the cervix and bladder mucosa were histologically unreniarkablc. In the absence of any other genital or extragenital primary site, we conclude that this case represents a bilateral ovarian squamous cell carcinoma.
855
856
J. M.Radhi & S.M . Awnd
Discussion
We believe our patient represents the first report of bilateral squamous carcinoma of the ovary. A full post morteiii examination, and subxqucnt microscopical examination, showcd no evidence of other primary carcinoma within or beyond the genital tract. The available literaturc includes very fcw examples of primary squamous carcinoma of the ovary (Macko & Johnson 1983); most reported cases have been squamous carcinoma arising from either cystic tcratoma, Brcnncr tumour (Shingleton et al. 1974; Scully 1982), or ovarian endometriosis (Piver et al. 1978). ?'he most commnn sources of metastatic squamous carcinoma of the ovary are the cervix, vagina, bladder, skin, bronchus and oesophagus (Shingleton et a!. 1974). In the absence of any such source of squamous carcinoma, it can be assumed that primary squamous cell carcinoma has arisen from the ovarian surface epithelium, which exhibits Mullerian differentiation as it undergocs ncoplasia (Scully 198'2). Miillcrian type epithelium is capable of squaiiious differentiation and squamous elements are seen in cndometroid tumours and rarcly in mucinous and Rrenner turnours,. Ultrastructural evidence suggests that some of the rare epidermoid cysts of the ovary arise by metaplasia of coelomic epithelium and a primary squainous cell carcinoma may represent a malignant counterpart (Nogales & Silverberg 1976). In advanced disease as described in our patient, thc sourcc cannot b e identified with certainty but in the absence of Brenner t umour. endometriosis and epidermoid cyst, we postulate that the tumour was probably of surface epithelium origin. The number of reported patients with q u a m u u s cell ovarian carcinoma is too small to allow any valid con-
clusion rcgarding thc epidemiology or aetiology (Macko & Johnson 1983). Bilateral ovarian tumour may be due to multicentric origin or the turnour may be unilateral initially. with subsequent spread to the opposite ovary as part of extension throughout the pelvis (Scully 1982). Most reported patients have shown poor survival (Tetu er al. 1Y87) after combination of surgical, radiation and chemotherapy trcatnient due to the aggressive nature of thc tumour, inadcquatc surgical removal, advanced stage at the time of diagnosis. Our patient had a poor outcome, not only because of the advanced stage of the disease arid poorly dilferentiated tumour, but also because of her poor gencral condition. References Macko M. B. & Johnson L. A . (1983) Primary squamous ovarian carcinoma, a case rcport and review o f the literature. ('ancer 52, 1117-1119. Nogales F. F. Jr 6r Silverberg S. G . (1976) Epiderrnoid cysts of the ovary: a report of five cases with histogcnetic ultrastructural findings. Am J Ubsiet Gyne~01124,523-528. Piver. L. S. 6..Barlow .I. J . & 'Tsukada Y. (1978) Squamous cell carcinoma arising in ovarian endomctriosis. Gynecul Uncol6,200-337. Scully R. E. (1082) TUF~IOUTS of the Ovury arid M a l dewloped Gorrads. Arnicd Forces institute of Pathology, Washington, 1)C, pp 133-144. Shinglcton H. M.. Middleton F. F. & Gore 11. (1974) Squamous cell carcinoma in the ovary. Am J Obstet Gjnecol 120, 556-560. Tetu B . , Silva E. G. & Gershenson D. M. (1987) Squarnous cell carcinoma of the ovary. Arch Puthol Lab Med 111,864866.
Rewived 3 .Iunuury 1990 Arrepted 26 April I990
Bilateral squamous cell carcinoma of the ovary. Case report J. M. RADHI, S. M. AWAD
Case report
A 64-year-old multiparous woman presented with vague lower abdominal pain and swelling, associated with constipation and weight loss over 5 months. H e r past medical history included diabetes mellitus, pulmonary tuberculosis and a cerebrovascular accident causing right hemiplcgia and dysphagia. Examination showed features of right hemiplegia and slight conjunctival pallor. There was a hard, irregular pelvic-abdominal mass equivalent in size to ahout 16 weeks gestation. There were no dilated veins. skin metastasis or ascites. Pelvic examination confirmed the presence of a hard, irregular, fixed mass that could not be distinguished from the uterus. The cervix felt normal, but was fixed high behind the symphysis pubis. Invcstigation revealed normocytic anaemia (HI?8-9gidl. MCV 82 fl). Blood chemistry, liver function tests, chext X-ray and intravenous urography were all within normal limits. Ultram i n d showed a normal liver. no ascitcs and an irregular, large mass occupying most of the pelvis. Barium enema showed indentation of the sigmoid colon. After full bowel preparation, laparotomy was undertaken. This revealed an inoperable 'frozen pelvis' with large. fixed. bilateral ovarian turtiDepartment of Patholog!, 'I he Moncton Hospital, Moncton, New Bronswick, hlC 628, Canada I hl RADHI Department of Obstetrics and Gynecology, Charles S. Curti9 Memorial Hospital, St Anthony,
Newfoundland 4 0 K 4S0, Canada S M .4WAD Correspondence J M Radhi. M B , Dcpartment oi Pdthology, I h e Moncton Hospital, Moncton. New Brunswick kIC 6L8, Canadd
ours, metastatic seedlings on the peritoneum, liver and bowel surfaces and enlarged paraortic lymph nodes. 'The transverse. descending and sigmoid colon were adherent to the pelvic tumour and there was marked bowel distension, indicating subacute large bowel obstruction. Omentectomy was carried out and the large bowel was frced from adhesions to the tumour. A diagnosis of Stage IV ovarian carcinoma was made. Histological examination of the omentum showed a metastatic poorly diffcrcntiated, nccrotic, squamous cell carcinoma. Examination of the peritoneal fluid revealed clumps of ncoplastic squamous cells. A course oT chemotherapy was planned but the patient died, due to respiratory failure, 9 days after surgery. Autopsy rcvealed massive pulmonary oedema and recent myocardial ischaemia. The abdominal cavity contained 600 ml of' haemorrhagic fluid. There was a large pelvic mass adherent to the pelvic wall. Careful dissection showed that both ovaries contained lobulated, partly cystic and partly solid tumour with extensive necrosis, measuring about 15 X 10 X 10 cm on the right side cm on the Left side. Both ovarian and 1 3 ~ 1 2 x 8 tumours inliltrated the uterine and bladder walls but the endometrium, cervix and bladder mucosa wcrc normal. Extensive sampling of the ovarian masses showed a necrotic, poorly differentiated, squamous cell carcinoma with individual cell keratinization and small occasional keratin pearls. No evidence of teratoma, Brenner turnour: or endometriosis was seen. The endometrium was atrophic and the cervix and bladder mucosa were histologically unreniarkablc. In the absence of any other genital or extragenital primary site, we conclude that this case represents a bilateral ovarian squamous cell carcinoma.
855
856
J. M.Radhi & S.M . Awnd
Discussion
We believe our patient represents the first report of bilateral squamous carcinoma of the ovary. A full post morteiii examination, and subxqucnt microscopical examination, showcd no evidence of other primary carcinoma within or beyond the genital tract. The available literaturc includes very fcw examples of primary squamous carcinoma of the ovary (Macko & Johnson 1983); most reported cases have been squamous carcinoma arising from either cystic tcratoma, Brcnncr tumour (Shingleton et al. 1974; Scully 1982), or ovarian endometriosis (Piver et al. 1978). ?'he most commnn sources of metastatic squamous carcinoma of the ovary are the cervix, vagina, bladder, skin, bronchus and oesophagus (Shingleton et a!. 1974). In the absence of any such source of squamous carcinoma, it can be assumed that primary squamous cell carcinoma has arisen from the ovarian surface epithelium, which exhibits Mullerian differentiation as it undergocs ncoplasia (Scully 198'2). Miillcrian type epithelium is capable of squaiiious differentiation and squamous elements are seen in cndometroid tumours and rarcly in mucinous and Rrenner turnours,. Ultrastructural evidence suggests that some of the rare epidermoid cysts of the ovary arise by metaplasia of coelomic epithelium and a primary squainous cell carcinoma may represent a malignant counterpart (Nogales & Silverberg 1976). In advanced disease as described in our patient, thc sourcc cannot b e identified with certainty but in the absence of Brenner t umour. endometriosis and epidermoid cyst, we postulate that the tumour was probably of surface epithelium origin. The number of reported patients with q u a m u u s cell ovarian carcinoma is too small to allow any valid con-
clusion rcgarding thc epidemiology or aetiology (Macko & Johnson 1983). Bilateral ovarian tumour may be due to multicentric origin or the turnour may be unilateral initially. with subsequent spread to the opposite ovary as part of extension throughout the pelvis (Scully 1982). Most reported patients have shown poor survival (Tetu er al. 1Y87) after combination of surgical, radiation and chemotherapy trcatnient due to the aggressive nature of thc tumour, inadcquatc surgical removal, advanced stage at the time of diagnosis. Our patient had a poor outcome, not only because of the advanced stage of the disease arid poorly dilferentiated tumour, but also because of her poor gencral condition. References Macko M. B. & Johnson L. A . (1983) Primary squamous ovarian carcinoma, a case rcport and review o f the literature. ('ancer 52, 1117-1119. Nogales F. F. Jr 6r Silverberg S. G . (1976) Epiderrnoid cysts of the ovary: a report of five cases with histogcnetic ultrastructural findings. Am J Ubsiet Gyne~01124,523-528. Piver. L. S. 6..Barlow .I. J . & 'Tsukada Y. (1978) Squamous cell carcinoma arising in ovarian endomctriosis. Gynecul Uncol6,200-337. Scully R. E. (1082) TUF~IOUTS of the Ovury arid M a l dewloped Gorrads. Arnicd Forces institute of Pathology, Washington, 1)C, pp 133-144. Shinglcton H. M.. Middleton F. F. & Gore 11. (1974) Squamous cell carcinoma in the ovary. Am J Obstet Gjnecol 120, 556-560. Tetu B . , Silva E. G. & Gershenson D. M. (1987) Squarnous cell carcinoma of the ovary. Arch Puthol Lab Med 111,864866.
Rewived 3 .Iunuury 1990 Arrepted 26 April I990
