Chorionepithelioma of the fallopian tube

Chorionepithelioma of the fallopian tube

CHOl3IONEF’ITHELlOiLIS TOEM BUNNAG, M.D., OF THE I~ANGKOK, SIAM, READING, (Prom the Department FALLOPIAN AND TUBE M.D.. KACHXAN. CARL PA...

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CHOl3IONEF’ITHELlOiLIS TOEM

BUNNAG,

M.D.,

OF THE

I~ANGKOK,

SIAM,

READING, (Prom

the

Department

FALLOPIAN

AND

TUBE M.D..

KACHXAN.

CARL

PA.

uf Obstetrics CkriErc7mgkor~t~

ad Gyheoologff, 7Jnirwsit~f)

Siriraj

Hospital,,

0RNBURGER’S comprehensive and critical review (1932) of the literature on tubal chorionepithelioma, differing slightly in the recognit.ion accorded certain case reports included in the earlier reviews of Robert Meyer (1930), Dietrich (1926), and others, cites 33 bona fide descriptions of this tumor to 1932. Since the publieation of Niirnburger a further east has been reported by Stein. The following case, observed in Siam, appears to belong to the foregoing group of chorionepitheliomaa. If it be acceptable as a valid example of this type of growth, it possesses an added interest in being, along with the cases of Albert and de Senarclens, among the largest tubal chorionepitheliomas thus far described.

N

CASE.-Nallg

mal labors menstrual The irregular

R., Siamese, had ensued, the history irrelevant.

patient was admitted for thirteen months.

aged thirty? had twice previously last occurring two years ago. in

April, These

1932, complaining irregularities had

193’ Mar Apr B&y Jun Jut A@ 2q1 tit

l.-,Menstrual

Nor-

and

the menses had been as shown in Fig. 1,

l93.i b.n Fcb llIar Apr

Qq.xr-mnorrhea. metrorrkx&.

Hyp72.

fig.

i-fov kc

that been

been pregnant. Previous medical

and

record.

and had not been accompanied by symptoms of pregnancy nor indeed by symptoms of any kind whatsoever until four months l)efore admission. At that time a painful swelling had appeared in the left lower abdomen. The swelling had meanwhile grown rapidly, and the patieut had lost much weight and strength. No tissue had been passed per vaginam at any tirn(l during t,hc irregular bleedings. On mami.nation, the patient was found eachectic and the pulse was 130. The general physical examination and routinr laboratory findings were otherwise not pertinent. Abdominal examination showed a tender, movable cystic tumor the size of a six months’ pregnancy having a basal attachment in the left lower quadrant. There was evidence of a small amount of free fluid in the abdomen. The ztaginal examination showed a small amount of dark, unclotted blood issuing from the OS uteri. The vaginal and cervical appearances, however, were not suggestive of pregnancy. The cervix was snmll and fh*m, and the external OS practically closed. The slightly to the right by the corpus uteri was also small and firm, and was displaced The right ovary was indefinitely palpable. large left adnexal cystic mass. 276

BVNSAU-BACHMAN

The portive

provisional therapy

:

diagnosis Bhe patient

CHORIONEPITI~ELIOMA

OF

FALLOl?IAN

27i

TUBE

preliminary ovarian cyst. ” After to exploratory laparotomy.

was ‘ (malignant was submitted

sup-

Operation.--The peritoneum contained a moderate :unount of serosanguineous fluid. The tumor consisted of a dark, very irregularly surfaced and friable cyst, the walls of which were about 2 cm. in thickness. Aspiration for the purpose of reducing its bulk yielded over two liters of dark and blood-stained serous fluid. It was then found to be attached by a narrow pedicle to the outer end of the left tube, with light adhesions to the adjacent parametrial and pelvic peritoneum above and below the brim of the true pelvis on this side. The omcntum was broadly adherent to the upper pole of the tumor. Except in the latter features the peritoneum was not otherwise involved, nor was any gross “seeding” apparent; the peritoneal adhesions in the pelvic area separated readily without unusual oozing. The

left

ovary,

Fig.

Z.-Section

of the tumor. The uterus was

moderately

of

tumor

enlarged

showing (Zeiss

The right ovary small, firm and

and

both obj.

cystic,

hung

the Langhans 8; ocular 10.)

was also, apparently

but less normal.

frerly

and

distinctly

beneath

syncytial

enlarged

the

lowclr

type

and

of

pole

cell.

ryst.ic.

In the belief that a malignant fimbrial cyst was the explanation of the findings, operation was confined, in the patient’s weakened condition, to simple supracervical hysteroadnexectomy. Gross Pathologia &e’&nen.-The specimen removed at operation consisted of a degenerate and friable shell of tissue, resembling in color and texture the features of the maternal surface of a full-term placenta. Here and there on the surface of cyst wall, however, remnants of a serous capsule’ were recognizable. The outer end of the left tube was fused in the cyst wall, a patulous abdominal ostium was not located. The opposite tube was normal. The uterus was small and firm, its malls slightly thickened. The endometrium was velvety in appearance, clean except for a few punctate hemorrhagic spots, and was approxinlately 4 to 3 mm. in thickness. The left ovary was enlarged to about three times normal size by the presence of

278

AMERICAN

multiple in

cysts

certain

ovary

containing

instances,

was

Histologic

tissue The well

syneytial occasional

straw-colored

affected

serous

AND

fluid

opalescent

and

of

the

GYNECOILWY

lined

gragish

by yellow

tissue

but. was aplrrosimetely

EzcLmi?latiorc.---Fcctions

neoplastie

had

OBBTETRICY

only

tz&tnor

in

double

showed,

taking

the

syneytial

stains type

circumscribed well

masses, mitotie

and

outlined and

ceil small,

figures.

Fig. 3.-Emiometrium f’unetional stroma and ocular 10.

well,

of

and

ehorion actively

its normal

for

but

Inflammatory

but

proliferating

cells

a less

sharply

the

cells

were

in tubal chorionepithelioma. the scarcity of glandular

right

size.

most

Rerc eords

peripheral were

acidophilie

bound

tissue

The

part,

nuclei

The

seen.

eytaplasm with

numerous

figures

in masses

also

(Fig.

of The

than

large

a

and there of viable

chorionepitheliomatous

predominated

membranes, pale

indisputably

lutein

others.

of poorly staining degenerate tissue of unknown type. this framework, however, w;rre irregular masses and

character. la.tter

Oh

indeterminate

similarly

t.hiek matrix throughout

smaller,

JOUR,NAI>

nucleoli

the and

2).

decidua1 character are notable. Zeiss

of the obj. 8 :

The endo?~~elri~a~ was A to .3 ~mn. in thickness. Its surface was covered by a low euboidal type of epithelium. The stroma of the functional two-thirds was loose and deciduous in character, though not unusually congested. With the exoeption of certain large sinuses opening upon the uterine cavity, this portion was alThe Iatter were mainly most entirely lacking in characteristic glandular figures. confined to the st,iU compact basal layer of the endometrium, where a few tortuous stumps resembling in shape the pregravid type of gland were visible (Fig. 3). The

ovaries

showed

several

large,

cystic

persistent

follicles,

but

for

the

most

part were occupied by cysts exhibiting an irregular type of luteinized cell lining. Such lutein layers as were observed were disposed in patchy areas, the cells rather degenerate in appearance. Fibrous theeal ( ‘ organization ” was limited here and-there to attenuated strands of tissue averlying the inner surface of the lutein layers (Figs. 4 and 5).

BI!NNAG-HACHIMAN

:

~‘H0~ION~~ITHELIO~IA

Ok’

t’AI,LOI’IAN

E ‘urther Observations.-While the immediate postoperative were discoverable at the time these ful, and no metastases treated to report a final result. case has been too recently

Fig.

4.-Ovary

ning

E ‘lg. L-Ovary tion

of the

thin

in tubal chorionepithelioma. hyperplasia of theta interna

in tubal lutein

cell

Over-ripe layer.

and Zeiss

Atretic

lutein

chorionepithelioma. layer

and

hyperplasia ocular 10.

of the

‘l’l:

course notes are

cystic follkle. obj. 8 ; ocular

theta

IS

27!,

was unev rentthe recorded,

with 10.

be .gin-

cystoma : early hyalin ,izainterna. Zeiss obj . 8:

A . specimen of zLrCtle, collected postoperatively and preserved pher 101 mixture, was brought to Europe and there tested* by the * We are indebted to Prof. Hugo Sellheim of Leipzig for courtesies of case specimens. and in the study

with a glyce zinAsehheim-Zor t&k extended

In this

nlethod ination hormone

in June f 19X!, or about live weeks after lwing voided. showed it still eont:lined :ct that, time a conwntratinn in excess of 2511,OtlO mouse-units per liter.

Quantitative of anterior

exam pituitary

Con~,ww?&t.-Prom the theoretical standlloint p’~in~nry tubal ekorionepithelioma map be posuiblc of origin according to one of thrw methods : (1) It, may arise at the inkplantation site of a tubal luegnarwy iu a manner analogous to its origin at intraut&ine sites. Many of the tubal chorionepitheliomas thus far described appear to have had this so-called ‘~orthotol)ic ’ type of lmthogenesis. (2) As an “ectopic ’* growth the tumor may arise by the malignant transformation of benign or nlolnr chorionic emboli, lodged in the tubal vessels after deportation from an intrautcrinr, or other site of primary t~itlatiou. The thcoreticnl grounds for this type of pathogenesis are still 3 Pnbjrct of discussion: the aCtUa1 delllOnstI%tiOn is hW?t I 3,) The third possibility is a teratomn.tous or wit,11 many obvious difficulties. toratogenous origin. Illetastatid tubal c.horioncpithelioma. may present t,he appearance of an isolated and primary tuba.1 neoplasm if the true primary tumor, for example in thr uterus, has been expelled, resorbed, or overlooked. Reports of the disappearance of such but appear now to 1w well primary intrauterine t~nniors arc not only numerous, authenticated. The theoretical and prac.tica I difficulties underlying the demonstration of an indisputably primary tubal cl~orionepithrlioma are thus readily appreciated. In the present instance certain evidence needed for offering the case as an The inconclusive oxample of such a primary growth is unfortunately lacking. history and the prolonged delay prior to hospitalization are both unavoidable handicaps attending work among Oriental ln~ticnt.8. The atypical menstrual prot.oeol by It is no means excludes, hovwrr, tlw liossibility of an original octopic pregnancy. moreowr possible that the long neglect of the process was responsible for failure to identify beyond question the basic relationship between tumor a.nd tubal outium. lu spite of these deficiencies it is beliered a8 attempted through serial sections. that the remaining evidence is sufficient to suggest that the growth iu a primary tul~al chorionepithelioma, apparently arising as an i ’ orthotopic ” tumor on the sit.c of a 11revious tubal pregnancy. REFERENCES N&burger, L. : Veit-Stoeckel, Handbueh der Gya$kologie 8: 888, 1932. Robert: Handbuch der speziellen pathologischen Anatomie und Histologie 1930. Dietrich, A.: Halban-Seitz, Biologie und Pathologio des Weibes 1926. Hoehne, 0.: Halban-Seitz, Biologie und Pathologie des Weibes 1928. Stein, H. E.: AK J. 0~s~. & GYNEO. 23: 416, 1932. Albert: Niirnburger. de Senarctem: Cited by Niirnburger. Now&, E‘., amd Eoff, AILI. J. OBST. &r GYNEC. 20: 153, 1930. 221 XORTH

SIXTH

Ss~Evr

Meyer, 7-1: 750, 5-l: 37, 7-2: 723, Cited by A. K.: