Chorioadenoma destruens

Volume 88 !'\umber 4

Communications

sterile. The tubes and ovaries were atrophic but adherent. Dense fibrosis \vas palpated in the paracervical areas. None of the findings at operation suggested recurrent spread of the original cervical malignancy. During the course of removal of the uterus technical difficulties and a severe hypotensi\·e state necessitated abandonment of total removal and the subtotal operation v1as resorted to

and completed. The surgeon's postoperative diagnosis was postradiation state. multiple myomas of the uterus. cervical atresia, and pyometra. When the pathologist dissected the surgical specimen it appeared to him to be an ordinary myomatous uterus with the endometrium replaced by a pyogenic membrane. Accordingly, the random blocks taken for microscopic study did not include

those

neecssary

to

make

a

systematic

stOarch of the uterus at the line of excision. After learning of the presence of malignant disease in the first sections, he made recuts of the remaining tissue but orientation was difficult because of the fragmentation of the uterus by the first sectioning. Microscopic examination of the sections showed no evidence of normal or abnormal endometrium. In the 15 sections available for study there was a

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treatment of Stage II squamous cell carcinoma

of the cervix. 2. The uterus was also affected by multiple myomas and pyometra, the latter due to cervical atresia. 3. Neither the operating surgeon nor the pathologist anticipated encountering the condition, and neither took the steps necessary for compktc diagnosis or treatment. 4. Either one of two mechanisms which produce carcinoma in situ of the endometrial cavitv could have been opPrativt> in this patit'nt: surface spread from disease in the cervix, or malignant transformation of squa mnus mf'taplasia of the endometrium. The first method was considered more likely herP. REFERENCES

1. Cullen. T. S.: Cancer of the Uterus. New York, 1900, D. Appleton and Company. Friedell. G. H.: Obst. & Gynec. 12: 179. 19:i!l.

°

layer of squamous cell carcinoma in situ over most of the inner surface. There was minimal keratini-

zation on the luminal side of the diseased epithelium. The crust of carcinoma rested upon a base of smooth muscle. the myometrium, very strikingly different from the fibrous stroma of the cervix. Thcrr vvcre several foci of disease on the sections when' the epithelium dipped into the myometrium. producing pockets where the infection caused srnall abscesses. Both the uterine v.rall and the epithelium were infiltrated with inflammatory cells
Summary 1. Squamous cell carcinoma m situ was disco\·crcd in the uterus of a patient three and :1 half yt>ars after apparent successful radiation

Chorioadenoma destruens LOREN C. SPADEMAN, M.D. WILLIAM M. TUTTLE, M.D.t Department of Obstetrics and Gynecolog;' and the Division of Thoracic Surgery, Harper Hospital. Detroit, Michigan

This case report is of special intcrrst hecattsP of the long latent period between the removal of the utt'rus for chorioadenoma destrucns and the app<'arance of pulmonary metastasis. Mrs. K. W ., aged 36 years, gravida iv, para iii. was first seen on Oct. 22, 1953, at which time she was approximately 8 weeks pregnant. she complained of severe nausea and vaginal bleeding. and on November 16, the uterus was the size of a 5 months' pregnancy. X-ray examinations of the abdomen and chest revealed no evidence of a fetai structure. The lungs were normal. The bleedin~ became excessive, and the uterus enlarged rapidly to the size of a 6 months' pregnancy. On November 23, hysterotomy was performed and hydatid cysts were obtained from the uterine cavity thereby confirming the diagnosis of hydatidiform mole. Total hysterectomy was then performed for the following reasons: ( 1) The growth had increased very rapidly during the iast 7 days: ( 2) there had been continuous very profuse bleeding, with no evidence of uterine contractions, effacement. or dilation of the cervix: and ( 3) the patient was 36 yt>ars of age. had 3 children of her own and 2 tDeceast·d.

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Fig. 1. Photomicrograph of the metastatic lung lesion showing large trophoblastic cells from chorioadenoma destruens. (Hematoxylin and eosm xl68.)

adopted children. Both tubes and ovaries were normal. The pathological diagnosis was hydatidiform mole with no trophoblastic infiltration of the myometrium. The patient made an uneventful recovery. Friedman tests performed at monthly intervals were negative. In September, 1954, 10 months following the operation, the Friedman test became positive, and the patient complained of fullness and soreness in the breasts. X-ray examination of the chest revealed no lesions. Quantitative Aschheim-Zondek tests were positive at 10,000 and 50,000 M.U. This test was repeated a month later with similar result. On Jan. 1, 1955, the patient had hemoptysis, and the next day x-ray examination showed a solitary metastatic lesion measuring about 3 em. at its greatest diameter, located in a superior division of the right lower lobe of the lung. On January 14, partial lobectomy w~s performed by one of us (W.M.T.), and the finding was a discrete 4 em. tumefaction in the basal segments, the lateral portion of the right lower lobe of the lung. Resection of four basal segments \Vas done, leaving the superior segment intact. The nodule was composed of trophoblastic tissue with hemorrhage. The diagnosis was either choriocarinoma or chorioadenoma destruens. Slides of the uterus and lung were sent to the late Dr. Emil Novak and other members of the Albert Mathieu Chorionepithelioma Registry. It was their conclusion that the lesions were benign. She has remained in good health to the present, and repeated biologic tests and chest x-rays have failed to detect any recurrence of this disease 10 years later. It appears that the original diagnosis of choriocarcinoma was in error. Novak and Seah 1 stated that over half of the cases sent to the

Albert Mathieu Chorionepithelioma Registry with the diagnosis of choriocarcinoma are in fact benign. It appears, therefore, that this is an error which has been rather frequently made and the difficulties in diagnosis are v-.rell pointed up by Smalbraak. 2 The long latent period between the performance of the hysterectomy and the appearance of the pulmonary metastasis is worthy of note. REFERENCES

I. Novak, E., and Seah, C. S.: AM. J. 0BST. & GYNEC. 68: 376, 1954. 2. Smalbrak, ]. : Trophoblastic Growths, Amsterdam, The Netherlands, 1957, Elsevier Press, Inc.

A new gynecological instrument ALVIN M. SIEGLER, M.D. LOUIS M. HELLMAN, M.D. State U1tiversity of liew York Downstate Medical Center College of Medicine, Brooklyn, New York.

Prior to reconstructive oviductal operation the presence of organic occlusion must be confirmed and the point of tubal obstruction located. Preoperative techniques are not infallible and even at the time of laparotomy the gross tubal morphology may not reveal the true anatomic