COLLOID CAKCINOM \ OF 
THE OVAKV. 
MV 
CIIARI.KH ORKENK CUMSTON, M.D., 
Hoston, Mum. 
Reprint from Annual number. Vol, XII. 
ANNAI.M OK OYNMCOI.OdV AMI I*KIUATH\ 
Itnatnn, IWMt COLLOID CARCINOMA OF THE OVARY * 
CHARLES OREENE CUMBTON, M.n. 
Assistant Professor of Surgical Pathology in the Faculty of Medicine of 
Tufts College, Boston; Honorary >1 «*inl»«*r of the Surgical Society of 
Belgium; Fellow of the American Association of Obstetricians and 
Gynecologists; Corresponding Member of the Association of Genito- 
Hrinary Surgeons of France; of the Obstetrical and Gynecological 
Society of Paris; of the Pathological Society of Brussels, etc. 
The term colloid carcinoma lias been given to a typo of cancer 
containing a large amount of colloid substance; it lias been found 
in tho pylorus, the stomach, intestines, peritoneum, mammary 
gland, the liver, the kidney and ovary, although the two latter 
organs are less frequently the seat of this pathological process. 
The name of alveolar carcinoma has also been given to this type 
of neoplasm on account of its rnacroscopical appearance, hut the 
old surgeons employed this term in every case to growths which 
presented a more or less gelatinous consistency, and it has only 
been in recent years that this type of tumor has been considered 
a carcinoma, which has arrived at the highest state of colloid 
metamorphosis. 
Tho cause of colloid degeneration is probably to lie explained 
from the fact that in every carcinoma which has attained a cer- 
tain degree of development, a retrogressive metamorphosis takes 
place. For example, carcinoma of the mammary gland has a 
marked tendency to undergo fatty degeneration, while cancer 
arising in mucous membranes, covered with a cylindrical 
epithelium, will undergo a mucous metamorphosis. 
That colloid carcinoma is more prone to arise in the stomach, 
intestines or peritoneum, is due simply to the physiological proper- 
ties of the cell elements from which the neoplasm originates. Al- 
though Rindflcisch does not deny that a primary colloid 
metamorphosis can take place, he is, nevertheless, of the opinion 
that the principal part of tho colloid change takes place in the 
beginning, at the boundary line of the connective tissue and 
epithelium. 
According to this authority, if one examines the very charac- 
teristic picture of colloid carcinoma, and then if it he observed 
how tho groups of carcinoma cells lying in alveoli were in the 
•Presented l»y Invitation of the Section o£ Gy necology of the American 
Medical Ansoclation, ('olumltba, Old#, dhuMl !T. istty. • * %v,‘ 2 
CHARLES GREENE H MSTON. 
first place adherent to the walls of these alveoli, from which they 
are gradually separated by the formation of strata of colloid sub- 
stance, without being either increased or decreased, and how, 
at length, they atrophy and disappear after numerous strata of 
colloid material have become deposited,—all this can only jK>int 
to the fact that the greater amount of colloid substance is secreted 
at the boundary line of connective tissue and epithelium, although 
the fully developed epithelial cells are in no manner involved in 
the process. 
A direct transudation from the blood can, of course, not be 
admitted, because the endosmotic power of colloid substance is nil. 
On the other hand, it may be that in these cases the colloid sub- 
stance is a metamorphosed formative matter of the epithelial cells, 
like an albuminous body from which other types of carcinoma 
obtain an increase in the number of their cells. 
Arnold’s theory must here be considered. As is known, this 
authority believes that epithelial cells originate from an amor- 
phous matter, and if this theory Ik* correct, the accumulation of 
colloid substance can be easily explained as a simple collection 
of this amorphous formative substance. The concentric stratifi- 
cation of the colloid matter met with in these neoplasms, certainly 
indicates a periodicity in the process of secretion; the fatty and 
granular detritus, which composes a single layer, must probably 
be regarded as a secondary product of colloid formation. 
An example of this interesting pathologic process not long since 
was under our care, the history of the case being briefly as fol- 
lows: Mrs. Francis K., aged forty-nine years; menses began at 
the age of thirteen and were always regular every four weeks, the 
duration being about four days, until about a year ago, when they 
became irregular, occurring every six or seven weeks. The 
amount lost at each menstruation since this function had become 
irregular had been very considerably increased, almost to the ex- 
tent of a hemorrhage. For three months before coming under 
observation the patient suffered from a rather constant, dull pain 
in the pelvis and a burning sensation in the region of the umbili- 
cus. At the age of twenty-seven the patient gave birth to a 
healthy child at term, and has never l>een pregnant since. The 
appetite was poor, the tongue clean, and the bowels fairly regular. 
Sleep was somewhat disturbed, but the patient did not complain 
of headache. The inguinal glands on both sides wore found en- COLLOID CARCINOMA OF THE OVARY. 
3 
larged and hard, but they were not tender to pressure; there was 
no enlargement of the supraclavicular glands. Lungs and 
apparently normal. Analysis of the urine negative. 
By examination the abdomen was found somewhat enlarged 
and a number of dilated subcutaneous veins were visible in its 
lower half. There was a slight edema of the left leg. By palpa- 
tion a globular mass was found situated in the left side of the 
abdomen and extending from the corresponding iliac fossa to 
within about six centimetres of the umbilicus, while there ap- 
peared to be a narrow strip of percussion dullness extending from 
the mass over the lower part of the abdomen to the right iliac 
fossa. 
The vagina was roomy; bilateral laceration of the cervix, 
uterus was antiverted and apparently pushed forward by the mass 
Bimanual palpation revealed a fullness in Douglass cul-de-sac; the 
which was behind and to the left of the organ. The mass moved 
with the uterus, hut could not he distinctly limited from it. 
An exploratory laparotomy being advised and accepted, an in- 
cision about live centimetres long was made in the median line. 
As soon as the peritoneum was opened about '*oo cc. of colloid 
substance escaped from the abdominal cavity. Introducing three 
fingers into the incision, the following condition of affairs was dis- 
covered: The left ovary was the seat of a large colloid carcinoma 
about the size of an adult head, while the peritoneum of the pelvis 
was studded with small clusters of secondary nodules extending 
across to the right iliac fossa, and it was to the latter that was due 
the dullness on percussion. 
As it was more than useless to try to remove the growth, the 
abdominal incision was closed by several through and through 
wire sutures. The patient made an uninterrupted recovery, and 
was discharged in three weeks. 
Microscopical examination of the colloid matter, which was dis- 
charged through the incision when the peritoneum was opened, 
showed numerous spindle and polygonal shaped epithelial cells 
which were imbedded in a colloid stratum. 
The patient survived the operation seven weeks, and at her 
death permission was obtained to open the abdomen. The 
autopsy revealed a fibrinous peritonitis with secondary foci of 
colloid carcinoma, the left ovary being the starting point of the 
malignant process. 4 
CHARLES GREENE CUMSTON. 
The origin of colloid carcinoma of the ovary is obscure, and 
many authorities are of the opinion that the process develops in 
a preexisting ovarian cyst, and Rokitanski and Frerichs have par- 
ticularly insisted on the external similarity of colloid carcinoma 
and certain varieties of cystoma of the ovary. Cruvcilhicr and 
Rokitanski believed that this form of malignant transformation 
was most prone to arise in parvilocular types of ovarian cystoma, 
while Frerichs and Virchow do not admit this theory. The for- 
mer even went so far as to exclude colloid carcinoma from the ge- 
nus of cancer and placed it in the list of cystic neoplasms having a 
colloid contents. 
According to Waldeyer, it is quite {jossihlc to make a sharp 
distinction between colloid carcinoma and cystoma. An alveolar 
carcinoma is simply a type of carcinoma which forms a transition 
to cystoma, thus making, so to speak, a connecting link between 
the two, and is quite as justifiable, as for example—myxosarcoma, 
for they cannot he entirely separated from carcinoma or cystoma. 
This form of transition is not even necessary, inasmuch as a true 
medulary sarcoma can be found in cystic formations. It is use- 
less to dispute the point whether or not the cystoma belongs strict- 
ly to colloid carcinoma, or rice versa. 
There are clearly typical types which can only be described as 
true colloid cancers, and others which wo have to admit belong to 
the class of cystoma; and there are atypic forms which show the 
most varied conditions of transition. Waldeyer also says that if 
in its development an epithelial tumor shows a tendency to cystic 
formation, and if the single cysts coalesce so as to form larger 
cavities, and if this occurs throughout the entire neoplasm with- 
out in any way affecting the neighboring tissues, the application 
of the term cystoma is justifiable; while for those tumors where 
in spite of the colloid changes taking place in their cellular ele- 
ments and never forming larger cysts with special walls, with 
proliferating cell masses,and finally an extension of the tumor into 
the lymphatics and an invasion of the neighboring tissues, these 
should be called colloid cancer. 
If, on the other hand, the authorities who assert that colloid 
carcinoma is simply a carcinoma in its highest development are 
correct, then surely certain points must he considered which 
would also be in favor of a point or origin of this form of car- 
cinoma in the ovary. Provided that we maintain the theory of an COLLOID CARCINOMA OF TIIK OVAKV. 
5 
epithelial origin of ovarian cancer, tho development of colloid 
carcinoma in this organ can then be traced back to the epithelial 
elements contained within it, although there can l»e no positive 
proof as to whether ovarian carcinomata are developed from the 
remains of Pfluger’s tubes, or from (iruf’s follicles, or from the 
primary epithelial masses. 
Rindfleisch is the only modern authority who gives an opinion 
as to the origin of carcinoma of the ovary. lie admits the possi- 
bility that it originates from the follicles, or from the sites of the 
follicles; but, on the other hand, he believes that the endothelium 
of the lymphatics may undergo cancerous transformation. For 
the present, at any rate, tin* genesis of carcinoma of the ovary 
must bo looked upon as still unexplained. 
Regarding the character of colloid carcinoma of the ovary, it 
may be said that it can lx* either benign or malignant. Birch- 
-1 lirschfeld explains the benign character inasmuch as he says that 
the extensive; metamorphosis of the cells hinders the intensity of 
their proliferative power, and that consequently a slower course 
and a relatively lesser inclination for metastasis is present; but in 
this case, we must admit that the carcinomatous cells have under- 
gone a colloid metamorphosis and have lost their vitality, and that 
when they are carried to other parts of the economy, by either 
the blood or the lymphatic vessels, they do not form metastasis, 
and consequently cannot give rise to other foci of new formation. 
But there are a good many cases which show that this theory is 
not correct, at least in every subject, because the re is great 
malignancy which has been shown to exist, proven by the forma- 
tion of multiple metastases. For this reason, Foerstor contests 
the benign character of colloid carcinoma, and asserts that alveolar 
carcinoma of the ovaries always is accompanied by alveolar car- 
cinoma in other organs of the body, and he thus, consequently, 
denies the possibilities of a primary colloid carcinoma. It has 
been also olwerved that colloid carcinoma is found in other organs 
when it exists in the ovaries; but the secondary foci are not, cor- 
rectly speaking, a metastasis, but are more properly a direct exten- 
sion of the growth, and therefore the neoplasm generally remains 
confined to the organs in its immediate neighborhood. Such an 
extension would naturally take place more es|K*cially along the 
tubes towards the uterus. 
If we now consider the question of the age of patients who are CHARLES GREENE CUMSTON. 
affected with colloid carcinoma of the ovaries, it will be seen that 
it has little of importance in a certain sense, for it has been shown 
that carcinoma of the ovaries attacks young people during, or even 
before, puberty, while in most all other viscera cancer is usually 
met with at a more advanced age, particularly at al>out the time 
of the menapause. Leopold mentions a case of a girl, aged twelve 
and a half years old, who had a cancer of one ovary weighing four 
pounds and a half, and Winkel and Olshausen, from their ex- 
perience, believe that puberty and immediately after it is a very 
propitious time for the development of carcinomatous transforma- 
tion in the female genital glands. It must not be understood that 
colloid cancer of the ovary cannot also arise in older persons, and 
this is shown by the case here related as well as many other re- 
corded cases, all of whom were women who were at or had passed 
the menopause. This latter fact as well as the fact that young 
people are not exempt from colloid cancer of the ovary would al- 
low the conclusion that this affection is independent of the age of 
the patient. 
If we consider the character of the menses in subjects atllicted 
with this form of carcinoma we will note that there is in the iirst 
place an irregularity with long intervals and considerable loss of 
blood at the time; clots may also be present. This characteristic 
which is at variance with the general rule, as well as the entire 
absence of menstruation and other anomalies of this function, 
would naturally not allow one to make a diagnosis of a malignant 
tumor of tin* ovary, and we should never lay too much importance 
on the menstrual function when making a diagnosis of ovarian 
diseases, because Leonid found that in sixty cases of ovarian tu- 
mors the menstruation showed quite a varying conduct under sim- 
ilar pathologic conditions, and it has also been well demonstrated 
by Olshausen that it is only by a complete al>senco of the menses 
that we have one of the earliest signs of an ovarian neoplasm. 
The commencement of a colloid cancer of the ovary is never in- 
dicated by any definite symptoms and must therefore bo classed 
among the so-called latent neoplasms. The first symptoms com- 
plained of usually are burning pains in the region of the sacrum 
and in the abdomen. To this will soon be added a sensation of 
weight and an unpleasant tension in the abdomen. As soon as the 
tumor has reached a certain stage its growth then becomes rapid, 
a circumstance which generally first calls the patient’s attention to COLLOID CARCINOMA OF TIIK OVARY. 
7 
her trouble and causes her to seek medical advice. Those phe- 
nomena are not characteristic in every case, for occasionally only 
moderate pains exist or may he even wanting while the rapidity 
of growth of the tumor will naturally vary in each case. 
An important symptom is the appearance of ascites which can 
easily he demonstrated by percussion dullness as well as by the 
change of the dullness when the position of the patient is changed, 
and in the large majority of cases it is present in a more or less 
considerable degree. Ascites is usually looked upon as a phe- 
nomenon indicating pressure because the vessels of the abdomen 
and pelvis are compressed by the increasing size of the tumor; it 
also may he due to a peritonitis, which in its turn, may he pro- 
duced by the affected ovary as well as to the relation between the 
latter and the peritoneum covering it. The pains may also be 
attributed to an irritation of the peritoneum. 
Ascites, which is present in malignant ovarian tumors, is not in- 
frequently accompanied by an edema of the lower extremities; 
this latter symptom may be explained by pressure of the tumor 
on the pelvic vessels, and Olshausen believes that it is also pro- 
duced by the compression of the veins by infiltrated lumbar 
glands. 
The presence of matastases in other organs is naturally of con- 
siderable diagnostic value, but is characteristic of carcinoma in 
general. The lymphatic glands are more especially affected, 
above all those' that are in the immediate region of the neoplasm. 
In carcinoma of the ovary the glands of the inguinal region appear 
to he very frequently involved, and I may add that as in the case 
of malignant tumor of the testicle in the male, the ovary, when the 
seat of a malignant, transformation, may also give rise to a sec- 
ondary deposit in the supraclavicular glands. 
When once the lymphatic system has become affected the road 
is open for the transportation of the malignant genus to more re- 
mote parts of the body. 
As to tho physical characters of colloid cancer of the ovary it 
may he said that in those cases where the ascites docs not interfere 
with abdominal palpation, the tumor either was found to he flue 
tuating or else presented an uneven nodular surface. 
The progress of colloid cancer of the ovary may naturally he 
surmised by what has already been said and an unfavorable prog- 
nosis is always to he given. 1 f the progress of the growth is slow 8 
riIAKLKS GKKKNK ( I MSTON. 
and gradual it may bo present for a considerable length of time 
before irritation of the peritoneum and the resulting ascites take 
place, and in those eases the patients are free from pain and 
feel fairly well. In the case of rapidly growing tumors the effect 
is very disastrous on account of the peritonitis and ascites as well 
as the emaciation and early cachexia. 
The diagnosis of colloid cancer of the ovary is, to say the least, 
very difficult, and in most eases is practically impossible, but we 
will rapidly review the symptoms of a malignant tumor of the 
ovary in general. These symptoms are ascites, metastases in the 
peritoneum, omentum or in Douglas cul-de-sac that may some- 
times be made out by a careful abdominal palpation and the pres- 
ence of enlarged inguinal glands; the rapid growth of the tumor, 
the abdominal pains, oedema of the lower extremities, emaciation 
and cachexia. 
The above mentioned symptoms would naturally lead the sur- 
geon to make a diagnosis of malignant tumor, and if wo compare 
these symptoms with those present in a carcinoma, sarcoma or cys- 
toma of the ovary we will find that the symptomatology is practi- 
cally the same. In making a differential diagnosis between car- 
cinoma and sarcoma of the ovary and colloid carcinoma of the 
ovary it may be said that the latter differs in its physical charac- 
ters to a certain extent. Carcinoma and sarcoma show a more 
uniform consistency, while colloid carcinoma is in part fluctuating 
and partly solid with a nodular and irregular surface. This con- 
dition, however, is also characteristic of ovarian cystoma, so that 
a clinical differentiation between these two growths cannot as a 
rule be made with any degree of certainty and consequently an 
exploratory incision is the proper course to pursue in order to as- 
certain the true nature of the growth. 
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