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Early detection of chorionepithelioma by means of the anterior pituitary hormone tests, with report of a case
CASTALLO:
893
CHORIONF,PITHELIONA
Hospital are any criterion as all the 8 women who were subjected to prompt surgical intervention survived. Again referring to this small series we find, as before noted, that 3 of the 8 were resutured while hysterectomy, the generally accepted operation of choice, was performed on 5 patients, including my own. My case would have been a simple one for resuture from the technical standpoint, and I was somewhat tempted to do it, but went on with the hysterectomy after briefly weighing in my mind the possible eventualities, namely, hysterectomy with loss of menstrual and childbearing function, but with less chance of deat,h from infection and resuture of a pot,entially infected uterus and a greater hazard of mat,ernal mortality. As it turned out t.lie patient and her baby are today alive a.nd well but I have frequently speculated as to what would have happened t.o her had I resntnred the rupture in an effort to save the uterus. 37
EAST SIXTY-FOURTEI
EARLY
DETECTION
OF THE
ANTERIOR
STREET
OF CHORIONEPITHELIOMA PITUITARY HORMONE REPORT OF A CASE
BY TESTS,
MARIO A. CASTALLO, A.B., M.D., D.N.B., PROVIDENCE, (From the Gyn~~logioal Services of St. Joseph’s Hospital)
MEANS WITH
R. I.
S
INCE chorionepithelioma is of chorionic epithelial origin, there has come into the realm of laboratory procedures a method for its detection. The AschheimZondek test and its modifications depend upon the presence of anterior pituitary hormone in the urine. However, while it takes 1 C.C. of urine to give a positive Aschheim-Zondek test in pregnancy, only l/50 C.C. of urine is required to give a positive test in hydatid mole, and only l/100 C.C. in chorionepithelioma. Thus a method of differentiation suggests itself. According to Anspach, 50 per cent of chorionepithelioma follows hydatid mole. The prognosis is bad in 80 per cent of cases, but in the individual case the earlier the operative procedure is instituted the better the prognosis.
There are about 45 cases of hydatid mole reported been followed or diagnosed by the Aschheim-Zondek nearly as many cases of chorionepithelioma have been with gratifying results. CASE
in the literature which have test or its modification, and followed in the same manner
REPORT
Mrs. E. B., aged twenty-eight. First admission to St. Joseph’s Hospital, Feb. 11, 1932. Patient’s chief complaint was vaginal bleeding, nausea and vomiting, and excessive weight of uterine enlargement. Patient’s last regular menstrual period occurred on Oct. 6, 1931. Previous period was on Sept. 4, 1931. The present vaginal bleeding started about Jan. 12, 1932, was spontaneous in origin, and moderate in amount; 2 to 3 napkins a day. The patient was placed abed, and the vaginal bleeding ceased. Since that time the patient has complained of slight bleeding every other day up until three or four days ago, when the patient began to bleed ex-
894
AMERICAN
JOURNAL
OF
vHSTETRIC‘S
AIW
GYNECOLOGY
cessively. She was placed abed once again and told by her family physician she was about to have a miscarriage. l’hc physician then inserted tampons the vagina. Patient stated that this pregnancy was mnelt heavier than her for the corresponding period of time. There was nothing clsc remarkable in history except that the patient began to vomit in November, 1931, which has tinued up to the past week.
that into first, the cot,-
She had been married four years, had one child, now eighteen months old; :I. normal birth. No miscarriages. Physical examination showed a poorly nourished and developed white female, markedly anemic and with an anxious expression. Colostrum could be expressed. A nontender mass in the abdomen extended to the navel. There was vaginal bleeding. Rectal examination revealed several hard masses in the vagina, and the cervix was about 1 finger’s breadth dilated. A diagnosis was made of inevitable abortion.
Fig.
1.
Fig. L--Uterine curettings March 30, 1932. chorionepithefioma proliferation of syncytial and Langerhans layers. Fig. 2.-Chorionepithelioma of uterus April 23, 1932. Representing described in fundus of the uterus folIowing the panhysterectomy.
(early). the
A typ?tical tumor
mass
At lo:30 P.M. of the day of admission, the patient had severe cramplike pains in the abdomen and passed by vagina several tampons and a very large amount of a “tapioca-like ’ ’ substance. An Aschheim-Zondek test was started on urine obtained the next morning which dosage, and also in the l/50 OX. gave a positive reaction in the regular urine dilution, which suggested hydatiform .mole. On February 13, a dilatation and curettage of the uterus was done and many grapeliie bodies were removed. Urine collected four days postoperative, Feb. 17, 1932, and reported ‘February 22 gave a positive Aschheim-Zondek react&n. On the twenty-third day of February an Aschheim-Zondek test gave a negative reaction unexplainable considering what followed. As follow-up, a specimen of urine was collected one month later on March 26. A Friedman (rabbit) test wag done and this revealed a strongly positive reaction. Because of the positive teat for anterior pituitary hormone in the urir& the patient was readmitted, even though symptomless, on March 30 for a aiIat&on
CASTALLO
:
895
CHORIONEPITHELIOMA
and curettage. We believed that the mole was not completely evacuated at the first operation. At this time the uterus was found to be about twice its normal size. The curettings revealed only a small amount of material and no grapelike or tapiocalike particles. The pathologic report at this time revealed marked atypical proliferation of the spncytial and Langerhan’s layers. This picture (Fig. l), coupled with persistent positive Aschheim Zondek test, led us to advise panhysterectomy, which was done on April 23. No gross pathology was evident at operation. The patient made an uneventful recovery. Pathologia Report.-The uterus did not appear enlarged or unusual. The endometrium presented a very slight thickening, but otherwise was not remarkable except for a tiny area of dark discoloration about 2 mm. in size, situated in the center of the highest point in the fundus. Longitudinal section of the uterus and ccrrix was made through this area. On section, beneath this area, there was an
Fig. 3.-Chorionepithelioma of uterus April 23, 1932. Area surrounding the small tumor mass in the fundus of the uterus. The tumor mass is completely separated from any identified uterine musculature by a thick wall of lymphoid cells. Section shows lymphoid cells adjacent to uterine musculature. hemorrhagic spot firm in consistency, mottled with tiny pearly areas 6 mm. in diameter, with the greater portion embedded into the uterine musculature and a very small portion reaching the deeper layers of the endometrium. The tubes and ovaries presented nothing unusual. Microscopic examination showed chorionepithelioma. There was no evidence of metastasis found in tubes or ovaries. Figs. 2 and 3 showed the microscopic pictures. May 5, 1932, x-ray of the chest was reported negative. bn June 2, 1932, and on July 10, 1932, follow-up Aschheim-Zondek tests gave negative reactions. Six months later, a third follow-up test, also gave a negative reaction. To date (August, 1933) the patient has remained well. I desire to thank Dr. Constable for the &Quirk in whose service the case occurred. 255 THAYER
STREET
microphotographs,
and
Drs.
Coughlin
and
893
CHORIONF,PITHELIONA
Hospital are any criterion as all the 8 women who were subjected to prompt surgical intervention survived. Again referring to this small series we find, as before noted, that 3 of the 8 were resutured while hysterectomy, the generally accepted operation of choice, was performed on 5 patients, including my own. My case would have been a simple one for resuture from the technical standpoint, and I was somewhat tempted to do it, but went on with the hysterectomy after briefly weighing in my mind the possible eventualities, namely, hysterectomy with loss of menstrual and childbearing function, but with less chance of deat,h from infection and resuture of a pot,entially infected uterus and a greater hazard of mat,ernal mortality. As it turned out t.lie patient and her baby are today alive a.nd well but I have frequently speculated as to what would have happened t.o her had I resntnred the rupture in an effort to save the uterus. 37
EAST SIXTY-FOURTEI
EARLY
DETECTION
OF THE
ANTERIOR
STREET
OF CHORIONEPITHELIOMA PITUITARY HORMONE REPORT OF A CASE
BY TESTS,
MARIO A. CASTALLO, A.B., M.D., D.N.B., PROVIDENCE, (From the Gyn~~logioal Services of St. Joseph’s Hospital)
MEANS WITH
R. I.
S
INCE chorionepithelioma is of chorionic epithelial origin, there has come into the realm of laboratory procedures a method for its detection. The AschheimZondek test and its modifications depend upon the presence of anterior pituitary hormone in the urine. However, while it takes 1 C.C. of urine to give a positive Aschheim-Zondek test in pregnancy, only l/50 C.C. of urine is required to give a positive test in hydatid mole, and only l/100 C.C. in chorionepithelioma. Thus a method of differentiation suggests itself. According to Anspach, 50 per cent of chorionepithelioma follows hydatid mole. The prognosis is bad in 80 per cent of cases, but in the individual case the earlier the operative procedure is instituted the better the prognosis.
There are about 45 cases of hydatid mole reported been followed or diagnosed by the Aschheim-Zondek nearly as many cases of chorionepithelioma have been with gratifying results. CASE
in the literature which have test or its modification, and followed in the same manner
REPORT
Mrs. E. B., aged twenty-eight. First admission to St. Joseph’s Hospital, Feb. 11, 1932. Patient’s chief complaint was vaginal bleeding, nausea and vomiting, and excessive weight of uterine enlargement. Patient’s last regular menstrual period occurred on Oct. 6, 1931. Previous period was on Sept. 4, 1931. The present vaginal bleeding started about Jan. 12, 1932, was spontaneous in origin, and moderate in amount; 2 to 3 napkins a day. The patient was placed abed, and the vaginal bleeding ceased. Since that time the patient has complained of slight bleeding every other day up until three or four days ago, when the patient began to bleed ex-
894
AMERICAN
JOURNAL
OF
vHSTETRIC‘S
AIW
GYNECOLOGY
cessively. She was placed abed once again and told by her family physician she was about to have a miscarriage. l’hc physician then inserted tampons the vagina. Patient stated that this pregnancy was mnelt heavier than her for the corresponding period of time. There was nothing clsc remarkable in history except that the patient began to vomit in November, 1931, which has tinued up to the past week.
that into first, the cot,-
She had been married four years, had one child, now eighteen months old; :I. normal birth. No miscarriages. Physical examination showed a poorly nourished and developed white female, markedly anemic and with an anxious expression. Colostrum could be expressed. A nontender mass in the abdomen extended to the navel. There was vaginal bleeding. Rectal examination revealed several hard masses in the vagina, and the cervix was about 1 finger’s breadth dilated. A diagnosis was made of inevitable abortion.
Fig.
1.
Fig. L--Uterine curettings March 30, 1932. chorionepithefioma proliferation of syncytial and Langerhans layers. Fig. 2.-Chorionepithelioma of uterus April 23, 1932. Representing described in fundus of the uterus folIowing the panhysterectomy.
(early). the
A typ?tical tumor
mass
At lo:30 P.M. of the day of admission, the patient had severe cramplike pains in the abdomen and passed by vagina several tampons and a very large amount of a “tapioca-like ’ ’ substance. An Aschheim-Zondek test was started on urine obtained the next morning which dosage, and also in the l/50 OX. gave a positive reaction in the regular urine dilution, which suggested hydatiform .mole. On February 13, a dilatation and curettage of the uterus was done and many grapeliie bodies were removed. Urine collected four days postoperative, Feb. 17, 1932, and reported ‘February 22 gave a positive Aschheim-Zondek react&n. On the twenty-third day of February an Aschheim-Zondek test gave a negative reaction unexplainable considering what followed. As follow-up, a specimen of urine was collected one month later on March 26. A Friedman (rabbit) test wag done and this revealed a strongly positive reaction. Because of the positive teat for anterior pituitary hormone in the urir& the patient was readmitted, even though symptomless, on March 30 for a aiIat&on
CASTALLO
:
895
CHORIONEPITHELIOMA
and curettage. We believed that the mole was not completely evacuated at the first operation. At this time the uterus was found to be about twice its normal size. The curettings revealed only a small amount of material and no grapelike or tapiocalike particles. The pathologic report at this time revealed marked atypical proliferation of the spncytial and Langerhan’s layers. This picture (Fig. l), coupled with persistent positive Aschheim Zondek test, led us to advise panhysterectomy, which was done on April 23. No gross pathology was evident at operation. The patient made an uneventful recovery. Pathologia Report.-The uterus did not appear enlarged or unusual. The endometrium presented a very slight thickening, but otherwise was not remarkable except for a tiny area of dark discoloration about 2 mm. in size, situated in the center of the highest point in the fundus. Longitudinal section of the uterus and ccrrix was made through this area. On section, beneath this area, there was an
Fig. 3.-Chorionepithelioma of uterus April 23, 1932. Area surrounding the small tumor mass in the fundus of the uterus. The tumor mass is completely separated from any identified uterine musculature by a thick wall of lymphoid cells. Section shows lymphoid cells adjacent to uterine musculature. hemorrhagic spot firm in consistency, mottled with tiny pearly areas 6 mm. in diameter, with the greater portion embedded into the uterine musculature and a very small portion reaching the deeper layers of the endometrium. The tubes and ovaries presented nothing unusual. Microscopic examination showed chorionepithelioma. There was no evidence of metastasis found in tubes or ovaries. Figs. 2 and 3 showed the microscopic pictures. May 5, 1932, x-ray of the chest was reported negative. bn June 2, 1932, and on July 10, 1932, follow-up Aschheim-Zondek tests gave negative reactions. Six months later, a third follow-up test, also gave a negative reaction. To date (August, 1933) the patient has remained well. I desire to thank Dr. Constable for the &Quirk in whose service the case occurred. 255 THAYER
STREET
microphotographs,
and
Drs.
Coughlin
and