Multiple Fibromyomata of the Uterus in association with an Ovarian and Anal Fibromyoma.

Report of a Case

BY

JOCELYN MOORE, M .B., B.S. (Lond.) , F.K.C.S. (Eng.) , M. c. 0. G .

Second Assistaiil, Obstetrical Uni2, Royal Free Hospital.

THIS case is interesting to report on account of the rarity of an anal tumour identical in structure with the uterine fibromyo- mata. The presence of an ovarian fibroma is an additional feature of the case. The presence of the anal fibromyoma is difficult to explain from the point of the aetiology and histo- genesis of fibromyomatous turnours in general.

The case history is as follows :

The patient was a nullipara, aged 43 years, who had bcwi twice married; she attended the out-patient department complaining of “a lump at the back passnge” antl profuse periods. The l u n i p had brcn nciticed for eight months and caiised i r rh t ion as the solc symptom. ‘The menstrual history was as follows: Periods a t iutervals five to six wt!oks and of five to six days’ duration with very heavy loss for three days. The only previous i l l ~es s corripla.iiie,d of was rheumatic fever a t thc age of 24 years.

On admission, May $th, 7934, th(5 gc.nr:ral condition was good. Compensated mitral stenosis was prtwnt.

She had secondary anaemia. Blood count : 1I.B.C. 4,2oo,ooo. Hb. 54 per cent. C.T. 0.6.

W.B.C. 5,300.

Local condition. Abdomen : A mass was found rising out of the pelvis and extending

This had not been noticed l y the

Per vnginavn: The cervix was normal antl the uterus enlarged by

Anus: There was a small round hard riiass at the right postpro- No evidence

up to the level of the umbilicus. patient.

fibroids .

lateral quadrant of the anus, superficial to the sphincter. of inflammation was present.

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MULTIPLE FIBROMYOMATA OF THE UTERUS

Oper,ation, May ISth, 1934. The abdomen was opened through a median sub-umbilical incision.

The uterus was enlarged by one large and several small sub-peritoneal fibroids. The right ovary was also enlarged by a tumour t h e size of a hen’s egg projecting from the inner pole. The left Fallopian tube and ovary were normal. Right salpingo-oophorectomy and sub-total hysterec- tomy were performed, followed by dissection and enucleation of the anal tumour.

The post-operative progress was uneventful and the patient was dis- charged well 19 days after the operation.

Pc(2hologist’s report. The specimen consists of a ntcrus renioved by sub-total hysterectomy,

right Fallopian tube and ovary antl a solid tumour from the anal region. ’rite uterus is enlarged by one large and several small interstitial fibroids. A small pedunculated sub-peritoneal fibroid and a very small sessile sub-peritonpal fibroid are present on the posterior surface. The uterine cavity is elongated and the endometrium is extremely thickened and polypoid. Thts right ovary is enlarged, measuring 6 x 3 x 3 centimetres. An oicapsuiatrtl roiind fibroma, three centimetres in diameter. is present a t its inner pole. The anal tiimour is a solid firm encapsulated tumour mciasriring 5 x 3”-. x z centi1nrtrc.s. Thta cu t surface shows a grey or white

The section of thr walls of the fundus show well-marked polypoid Ihiclienirig of the endometrium. Thwe is hyperplasia of glands and stroma antl considerable infiltration of the latter by lymphocytes and plasma cells. The section of the ovarian fibroma shows the typical structure of a fibroma.

\vhotlecl appearance.

Sections show thc. anal firmour to a fibromyomn.

I t is difficult to co-relate the histogenesis of the perianal fibro- inyoma with the fibromyoma ta of the uterus. The possibilities To be considered are:

I , Migration “Burrowing” from the uterus. This would mean that the anal fibromyorna would have had to have travelled from the uterus round the rectum i‘rom the anterior to posterior surface and finally to have passed through the external anal sphincter to become superficially placed at the right postero- lateral aspect of the anal orifice. This possibility does not seem feasible.

2. Enzhvynnnl rests. Cohnheim’ believed that any embryonal rest in the uterus might give rise to a fibroid tilmour. It is difficult to explain the prcsence of a perianal fibromyoma by this theory.

3. Metaplnsia theoyy, Virchowz states that any muscle fibre of the uterus can give rise to a fibroid; therefore presumably any unstriped muscle in the region of the external anal sphincter may also be capable of producing a similar tumour. In this

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JOtJRNAL OF OBSTETRTCS AND GYNAECOLOGY

case, therefore, the presence of uterine and anal fibromyomata and an ovarian fibroma are mere coincidences or are due to some abnormal stimulus possibly derived from the ovary. Opitz, however, is of the opinion that fibromyomata arise from connec- tive tissue and not muscle tissue by a process of metaplasia. The connective tissue is the non-diff erentiated representative of mesoderm from which the muscle fibres later develop. Cohn- heim, in support of this, c la im to have traced the change from connective tissue to muscle in serial sections of small tibroids.

4. Sheaths of hlood-7)essels. Roesger ’ and others - claim that fibromyomatous growths spring from thc media and adventitia of small blood-vessels. This origin of extra-uterine fibroinyom;ita might again be the result of some abnonnal external stitnulns froin the ovary.

In the case under consideration the feasible theories ;I$ to the histogenesis of the multiple uterine and extra-utc>rinc fibro- myomata are those of metaplasia from the priniitivc connectivc tissue of the mesoderm, or from the coat of the small vessels which are themselves mesoderrnal in origin. This metaplasia might have resulted from abnormal ovarian stimulation. Another point in favour of this abnormal ovarian endocrine stimulation is shown in the endometrium of the uterus, which was consider- ably thickened and polypoid in character. The possibility of embryonal rests might account for the uterine fibromyomata, but docs not satisfactorily explain the anal tibromyoma. The question of niigratiori of a uterine fibroid to the pcrianal rcgion is impossible in this case from the pnrely anatomicd standpoint of the position of the tumour.

I am indebtcd to Professor name Louise McIlroy for per- mission to place this caw on record.

RFFERENCFS. I. Cohnheim. Viwh. ArcFt.. ~ 8 7 5 , lxv, 64. 2 . Virchow. Die Krankhnffen ~ r ~ c h ? ~ 1 i i k 1 f . 1863, i i i , ro7. 3. Roesgcr. 4. Lockyer. “New System of Gynaecology,” 1917. 5. Frank.

Zeilschr. f . Gebwtsh. 11. Gyniikol., r8q0, xviii, 1.31.

“Obstetrical and Gynaecological Pathology.” 1931.