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.: