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Metastatic chorionepithelioma of the lung treated by lobectomy
METASTATIC HERBERT
CHORIONEPITHELIOMA OF THE TREATED BY LOBECTOMY
LUNG
C. MAIER, M.D., AND HOWARD C. TAYLOR, JR., M.D., NEW YORK, N. Y. (From
the Thora&
and
Gynecological
Service
of Memorial
Hospital)
LTHOUGH a chorionepithelioma is usually a highly malignant tumor,.it may at times manifest an extraordinary digression from the usual clmA ical course. Unless hysterectomy is performed early, many eases go on to a
Pulmonary metastases occur frequently and often rapid, fatal termination. grow rapidly, and are important factors in mortality. Some cases of chorionepithelioma, however, run an atypical course. Cases have been reported in which there was incomplete removal of tumor tissue at the time of hysterectomy, and yet the remaining tumor disappeared spontaneously and the patient was well even years after operation. Regression and even disappearance of pulmonary metastases, either spontaneously or following radiation therapy, have been reported. Whereas an analysis of the literature reveals an appreciable number of cases of spontaneous disappearance of residual tumor in the pelvic region, there are only a small number of caseson record in which recovery has followed the presence of definite pulmonary metastases. Cases of so-called ectopic ehorionepithelioma have been reported in which no evidence of a primary tumor was found in the pelvic organs. Therefore, in some cases the chief factor in management is control of the metastastic lesion. The casewhich we are herewith reporting falls into this category. Case Report K. W., a 32-year-old woman, had a miscarriage in 193,5 and was delivered of a normal child in 1937. In 1939 occasional vaginal bleeding occurred for about three months. Operation for the removal of an hydatidiform mole was performed in October, 1939. A second dilatation and curettage was done in November, 1939. During the following two years eleven Aschheim-Zondek tests were done and found to be negative, but no roentgenogram of the chest was made. In April, 1942, irregular menstrual bleeding began. A roentgenogram of the chest then showed a small nodule in the right lower lung field. An Aschheim-Zondek test done at the same time was reported negative. A second roentgenogram taken in September, 1942, showed that the mass in the right lung had more than doubled in size when compared with the film taken five months previously. In October, 1942, the Aschheim-Zondek test became positive. The following month another dilatation and curettage was performed, but examination of the tissue revealed no tumor or decidual tissue. The patient had amenorrhea from August, 1942, to January, 1943, and during this time the mass in the lung increased in size. In November, 1942, radiation therapy was given to the chest over the site of the tumor; 2,100 roentgens total was given to each of two fields through 10 cm. circular ports at 70 cm. target skin distance, 1,000 K.V. A daily dose of 300 roentgens was given to alternating fields. Following therapy there was little change in the size of the mass, as seen on the roentgenogram. Another Aschheim-Zondek test in November was again positive. In March, 1943, the first hemoptysis occurred and there was roentgen evidence of further enlargement of the mass in the right lung (Fig. 1). On the basis of the history of the hydatid mole with the subsequent appearance of a mass in the lung, together with positive Aschheim-Zondek tests, a diagnosis of metas674
Volume 53 Number 4
Fig.
Fig.
CHORIONEPITHELIOMA
l.- -Preoperative
Z.-Operative
roentgenogram
specimen
showing
OF
of chest
showing
large
metastatic
LUNG
&ass
675
at base
chorionepithelioma
of 1:ight
lung.
in lung.
676
Fig.
I.-Rnentgenogram
of
chest
MAIER
AND
one
one-half
and
Am J. Ob,t. & Gym. April, 1947
TAYLOR
years
after
right
lower
lobi~
l~~bwtorn~.
Volume Namhr
53 4
CHORIONEPlTHELIOMA
OF
LUNG
677
The possibility of an tatic chorionepithelioma of the lung seemed most probable. independent tumor of the lung could not be entirely ruled out because of the relatively slow growth and the failure to find evidence of tumor in the pelvic organs. Because of the atypical course of the tumor, it was felt justified to remove the pulmonary mass, even though it might be a metastatic lesion. Consequently, on March 25, 1943, a right lower lobe lobectomy by the hilar dissection technique was performed. The postoperative course was entirely uneventful. An Aschheim-Zondek test done a day before lobectomy was positive, whereas another test done a day after operation was negative. Pathologic report of the lobe of the lung was as follows : Dissection of the lower lobe bronchus and branches showed no evidence of obstruction. On section there was a large, ovoid, circumscribed tumor mass measuring 6.5 by 6 by 5 cm. which did not involve a bronchus (Fig. 2). About three-fourths of a centimeter from this mass was a second small nodule less than one centimeter in diameter. On cut section t,he main tumor mass, as well as the other small nodule, was very hemorrhagic in the center, and elsewhere white and rather granular looking. There appeared to be a direct extension of the tumor into an adjacent anthracotic peribronchial lymph nodes. On microscopic examination the findings were typical of chorionepithelioma (Fig. 3). On April 27, 1943, a complete hysterectomy and bilateral salpingo-oophorectomy were performed. At the time of operation no tumor tissue was visible in the pelvic organs. Careful examination of the entire specimen failed to reveal the presence of any tumor in the uterus or adnexa. Over three years have elapsed since lobectomy was performed, and the patient has been in excellent general condition, free of all symptoms or evidence of disease, and repeated roentgenograms of the chest have failed to reveal any further pulmonary metastases (Fig. 4). Aschheim-Zondek tests have been done at regular intervals and all reports have been negative. This case is an example of a chorionepithelioma running an atypical course. Whereas in most instances the pulmonary metastases grow rapidly and cause a fatal outcome in a matter of weeks, it is known that a pulmonary metastasis was present in our case for at least eleven months prior to its removal by lobectomy. Radiation therapy seemed to be of little benefit in our case, but this statement should not be interpreted as infer@ that irradiation is not of value in some cases of metastastic chorionepithelioma. Realizing that we were dealing with an atypical case of chorionepithelioma, an attempt to remove the pulmonary metastasis by lobectomy seemed justified. We feel that the lobectomy was of great value in the treatment of this particular patient, but realize that a similar procedure would rarely be applicable in chorionepithelioma with pulmonary metastases. Whether the panhysterectomy done following lobectomy has been a factor in the failure of the patient to show further evidence of disease can only be conjectured. summary A case of metastatic chorionepithelioma of the lung successfully treated by The Aschheim-Zondek test which was positive prior to lobectomy is reported. operation became negative following lobectomy. Panhysterectomy performed a month after lobectomy failed to reveal any evidence of disease in the pelvic The patient is well and free of evidence of disease over three years folorgans. The plan of therapy pursued in this case could lowing pulmonary lobectomy. be feasible only in a very small percentage of cases of chorionepithelioma.
CHORIONEPITHELIOMA OF THE TREATED BY LOBECTOMY
LUNG
C. MAIER, M.D., AND HOWARD C. TAYLOR, JR., M.D., NEW YORK, N. Y. (From
the Thora&
and
Gynecological
Service
of Memorial
Hospital)
LTHOUGH a chorionepithelioma is usually a highly malignant tumor,.it may at times manifest an extraordinary digression from the usual clmA ical course. Unless hysterectomy is performed early, many eases go on to a
Pulmonary metastases occur frequently and often rapid, fatal termination. grow rapidly, and are important factors in mortality. Some cases of chorionepithelioma, however, run an atypical course. Cases have been reported in which there was incomplete removal of tumor tissue at the time of hysterectomy, and yet the remaining tumor disappeared spontaneously and the patient was well even years after operation. Regression and even disappearance of pulmonary metastases, either spontaneously or following radiation therapy, have been reported. Whereas an analysis of the literature reveals an appreciable number of cases of spontaneous disappearance of residual tumor in the pelvic region, there are only a small number of caseson record in which recovery has followed the presence of definite pulmonary metastases. Cases of so-called ectopic ehorionepithelioma have been reported in which no evidence of a primary tumor was found in the pelvic organs. Therefore, in some cases the chief factor in management is control of the metastastic lesion. The casewhich we are herewith reporting falls into this category. Case Report K. W., a 32-year-old woman, had a miscarriage in 193,5 and was delivered of a normal child in 1937. In 1939 occasional vaginal bleeding occurred for about three months. Operation for the removal of an hydatidiform mole was performed in October, 1939. A second dilatation and curettage was done in November, 1939. During the following two years eleven Aschheim-Zondek tests were done and found to be negative, but no roentgenogram of the chest was made. In April, 1942, irregular menstrual bleeding began. A roentgenogram of the chest then showed a small nodule in the right lower lung field. An Aschheim-Zondek test done at the same time was reported negative. A second roentgenogram taken in September, 1942, showed that the mass in the right lung had more than doubled in size when compared with the film taken five months previously. In October, 1942, the Aschheim-Zondek test became positive. The following month another dilatation and curettage was performed, but examination of the tissue revealed no tumor or decidual tissue. The patient had amenorrhea from August, 1942, to January, 1943, and during this time the mass in the lung increased in size. In November, 1942, radiation therapy was given to the chest over the site of the tumor; 2,100 roentgens total was given to each of two fields through 10 cm. circular ports at 70 cm. target skin distance, 1,000 K.V. A daily dose of 300 roentgens was given to alternating fields. Following therapy there was little change in the size of the mass, as seen on the roentgenogram. Another Aschheim-Zondek test in November was again positive. In March, 1943, the first hemoptysis occurred and there was roentgen evidence of further enlargement of the mass in the right lung (Fig. 1). On the basis of the history of the hydatid mole with the subsequent appearance of a mass in the lung, together with positive Aschheim-Zondek tests, a diagnosis of metas674
Volume 53 Number 4
Fig.
Fig.
CHORIONEPITHELIOMA
l.- -Preoperative
Z.-Operative
roentgenogram
specimen
showing
OF
of chest
showing
large
metastatic
LUNG
&ass
675
at base
chorionepithelioma
of 1:ight
lung.
in lung.
676
Fig.
I.-Rnentgenogram
of
chest
MAIER
AND
one
one-half
and
Am J. Ob,t. & Gym. April, 1947
TAYLOR
years
after
right
lower
lobi~
l~~bwtorn~.
Volume Namhr
53 4
CHORIONEPlTHELIOMA
OF
LUNG
677
The possibility of an tatic chorionepithelioma of the lung seemed most probable. independent tumor of the lung could not be entirely ruled out because of the relatively slow growth and the failure to find evidence of tumor in the pelvic organs. Because of the atypical course of the tumor, it was felt justified to remove the pulmonary mass, even though it might be a metastatic lesion. Consequently, on March 25, 1943, a right lower lobe lobectomy by the hilar dissection technique was performed. The postoperative course was entirely uneventful. An Aschheim-Zondek test done a day before lobectomy was positive, whereas another test done a day after operation was negative. Pathologic report of the lobe of the lung was as follows : Dissection of the lower lobe bronchus and branches showed no evidence of obstruction. On section there was a large, ovoid, circumscribed tumor mass measuring 6.5 by 6 by 5 cm. which did not involve a bronchus (Fig. 2). About three-fourths of a centimeter from this mass was a second small nodule less than one centimeter in diameter. On cut section t,he main tumor mass, as well as the other small nodule, was very hemorrhagic in the center, and elsewhere white and rather granular looking. There appeared to be a direct extension of the tumor into an adjacent anthracotic peribronchial lymph nodes. On microscopic examination the findings were typical of chorionepithelioma (Fig. 3). On April 27, 1943, a complete hysterectomy and bilateral salpingo-oophorectomy were performed. At the time of operation no tumor tissue was visible in the pelvic organs. Careful examination of the entire specimen failed to reveal the presence of any tumor in the uterus or adnexa. Over three years have elapsed since lobectomy was performed, and the patient has been in excellent general condition, free of all symptoms or evidence of disease, and repeated roentgenograms of the chest have failed to reveal any further pulmonary metastases (Fig. 4). Aschheim-Zondek tests have been done at regular intervals and all reports have been negative. This case is an example of a chorionepithelioma running an atypical course. Whereas in most instances the pulmonary metastases grow rapidly and cause a fatal outcome in a matter of weeks, it is known that a pulmonary metastasis was present in our case for at least eleven months prior to its removal by lobectomy. Radiation therapy seemed to be of little benefit in our case, but this statement should not be interpreted as infer@ that irradiation is not of value in some cases of metastastic chorionepithelioma. Realizing that we were dealing with an atypical case of chorionepithelioma, an attempt to remove the pulmonary metastasis by lobectomy seemed justified. We feel that the lobectomy was of great value in the treatment of this particular patient, but realize that a similar procedure would rarely be applicable in chorionepithelioma with pulmonary metastases. Whether the panhysterectomy done following lobectomy has been a factor in the failure of the patient to show further evidence of disease can only be conjectured. summary A case of metastatic chorionepithelioma of the lung successfully treated by The Aschheim-Zondek test which was positive prior to lobectomy is reported. operation became negative following lobectomy. Panhysterectomy performed a month after lobectomy failed to reveal any evidence of disease in the pelvic The patient is well and free of evidence of disease over three years folorgans. The plan of therapy pursued in this case could lowing pulmonary lobectomy. be feasible only in a very small percentage of cases of chorionepithelioma.