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Unsuspected abdominal chorionepithelioma
UNSUSPECTEDABDOlVIINALCHOBIONEPITHELIOMA H. ACOSTA-SISON, M.D., F.P.C.S., (Prom
the Departments
of Obstetrics
and
Gynecology,
E
MANILA, P. I. University
of the Philippinesj
VER since we lost practically all cases of chorionepithelioma, which were diagnosed only at autopsy, we had been vigilant of their occurrence and, in recent years, have felt the satisfaction of having saved many lives because of early diagnosis, making possible early radical treatment. So our failure to make the correct diagnosis in the present case, though markedly advanced when first seen, showed that we have much yet to learn about chorionepithelioma. L. P., 27 years old, laundress, entered the Philippine General Hospital on Sept. 13. 1947, because of an abdominal painless tumor. The patient claimed that she first noticed the tumor as an apple-sized mass in the lower abdomen, five months previous to admission. And at the same time, she also noticed that she began to have slight vaginal bleeding which was continuous for two and one-half months but which stopped for two months thereafter. However, the last two weeks before admission, the slight bleeding reappeared ofi and on. During this time, she also experienced slight afternoon rise of temperature. She had had three pregnancies, the first two of which ended in full-term deliveries ten years and five years, respectively, before admission. The third pregnancy ended in a four Menstrual periods after the abortion were months’ abortion one year previous to admission. normal, the last one occurring one month before the onset of the slight continuous bleeding. Physical examination showed that she was fairly well nourished though rather thin. Lungs and heart were apparently normal. The abdomen showed a large, firm, painless, slightly movable, globular tumor reaching up to the level of the umbilicus, the size of a six months ’ pregnancy. On vaginal examination, one could feel a small cervix connected with the uterus which was flattened and pushed to the left and posterior fornices by the large firm mass. There was slight. pinkish discharge from the external OS. Red blood count, 3,900,OOO; white blood count, 9,650; polymorphonuclear leucocytes, 77 per cent; lymphocytes 23 per cent,. Urinalysis normal. Blood pressure 110/70. Because of the finding of a firm, solid painless mass in the abdomen which was independent but intimately connected with the uterus, our first impression was a large subperitoneal fibroid. We could not, however, reconcile the diagnosis of a subperitoneal fibroid and the rapid growth of the tumor, which was noticed only five months previous to admission. But we felt that perhaps the tumor had existed unnoticed for sometime. Because of the rapidity of the growth, we considered the possibility of a malignant, tumor of the ovary. Chorionepithelioma was considered, but was immediately dismissed because of the firm consistency of the tumor and because the uterus could be distinctly outlined as separate from it. The patient was, therefore, scheduled for.operation three days later. On that day, however, she had cough and fever. In the belief that she was suffering from influenza, she was treated for this condition and the operation was postponed. But the fever, which was irregular, did not abate. On the contrary, as the days advanced, it became higher. Moreover, the patient began to complain of abdominal pain, tympanism, nausea and vomiting. At this time, we thought that what we regarded as a tumor was perhaps an encapsulated abscess which now began to leak into the peritoneal cavity and which needed immediate laparotomy, which was done on Oct. 2, 1947, under local anesthesia. On making a small incision on the peritoneum, an encapsulated mass looking like a large endometrial cyst was found. Aspiration revealed bloody content. After enlarging the abdominal incision and trying to evacuate the contents, we encountered a bloody mass of many small, firm, loose pieces of tissue attached to the intestines, omentum, uterus and posterior parietal peritoneum. We then thought we were dealing with a malignant growth of the 1195
1196
ACORTA-SISON
Am. J. Obst. & Gynec. December. 1948
ovary. But further exploration showed that both ovaries were intact, only that they were cystic. Since most of the bleeding came from the fundus of the uterus, we quickly did 9 subtotal hysterectomy and double salpingo-oophorectomy. After evacuating as much of the growth as possible and putting a firm gauze packing against the oozing surfaces, the abdominal incision was closed in the usual manner. Iinfortunately, we could not give blood transfusion L’or lack of a donor or blood bank. We gave four units of plasma, before, during, and after the operation, and continuous venoclysis of glucose solution. The patient became conscious after the operation, but succumbed two hours afterwards. Examination of the hysterectomized uterus showed a raw eaten-up fundus from which issued friable strands looking as if they had been pulled upwards. Sagittal section of the ntrrus showetl that the endometrium was clean without any trace of the growth. Both ovaries haJ bpen convrlted into corpus luteulrl psts 11~ sizca of a goose egg.
Autopsy revealed two more handfuls of growth attached to the intestines, omentum, and The lower lobe of the right lung showed a small focus of posterior pzrietal peritoneum. metastasis of the growth. Biopsy of the growth found in the lungs and abdominal cavity ~11o~ed syneytinm and Langhans (*ells with a predominance of the latter in some portions and of’ t.lu: former in other parts. C’omment:-Apparently, the contlit,ion begau as a myometrial chorionepithelioma which later extended to the right broad ligament and which rapidly grew in size. It was only in the last days, when the charionic cells had extended themselves beyond the confines of the broad ligament and serous surface of the uterus that internal bleeding, tympanism, abdominal pain supervened rapidly, threatening the life of the patient. Our inability to make preoperatively the correct diagnosis was due to the following: i 1) Because when first. seen, the size, consistency, and contour of the growth was suggestive more of uterine fibroid than of anyt,hing else. (2) The failure to associate the growth with the four months’ abortion which t,ook place seven months before she complained of bleeding. (,:‘,I The misinterpretation of the uterine bleeding that occurred later as part of the phenom(4) The fact that, she was in relatively good condition on admission, enon of uterine fibroma. in spite of the advanced condition of the growth. Because we erroneously thought chorionc~pithelioma was a remote possibility, no Friedman test was made, The reason the patient. here reported did not have early peritoneal bleeding, in spite of its being a myometrial growth that had gone beyond the uterus, is because the chorionic cells grew within the leaves
Volume Number
56 6
1197
CHORIONEPITHELIOMA
of the broad ligament which at first constituted itself as a firm capsule, giving shape and firm consistency to the growth in the same manner as happens in intraligamentous ovarian conditions or even pregnancy. The long interval of seven months that elapsed between her abortion and the occurrence From our experience with myometrial of the abnormal vaginal bleeding is not unusual. chorionepithelioma, in 55 per cent of the eight cases we had in 1942 to 1945, the vaginal bleeding did not manifest itself until from one year and two months to three years after the passage of the last product of conception which happened to be hydatidiform mole. Two of these cases were preoperatively diagnosed as cancer of the uterine corpus and two, because of symptoms of internal bleeding on admission, as ruptured tubal pregnancy. Had we seen the patient when she began to have continuous bleeding, had we felt the small mass in the lower abdomen, and associated such findings with her last abortion, we would have been able to diagnose her condition by the clinical method of diagnosis of uterine chorionepithelioma as first described by me.2 Even if our diagnosis then had been fibroma, she would have been saved by immediate laparotomy, which would have revealed the true condition of the uterus. If the correct diagnosis of abdominal chorionepithelioma had been made on her admission, what treatment should have been instituted? I believe the only hope for the patient then was x-ray treatment both for the abdominal and pulmonary growths. The
author
is greatly
indebted
to Dr.
Apelo,
who furnished
the photograph
of the uterus.
References 1. Aeosta-Sison, Early 2. Acosta-Sison,
H.: “Dangers of Myometrial Chorionepithelioma Caused by Failure of Diagnosis, ” J. Philippine College of Surgeons III: No. 1, Jan.-Feb., 1938. H., and Espinola, N.: AM. J. OBST. & GYNEC. 42: 878,1941.
the Departments
of Obstetrics
and
Gynecology,
E
MANILA, P. I. University
of the Philippinesj
VER since we lost practically all cases of chorionepithelioma, which were diagnosed only at autopsy, we had been vigilant of their occurrence and, in recent years, have felt the satisfaction of having saved many lives because of early diagnosis, making possible early radical treatment. So our failure to make the correct diagnosis in the present case, though markedly advanced when first seen, showed that we have much yet to learn about chorionepithelioma. L. P., 27 years old, laundress, entered the Philippine General Hospital on Sept. 13. 1947, because of an abdominal painless tumor. The patient claimed that she first noticed the tumor as an apple-sized mass in the lower abdomen, five months previous to admission. And at the same time, she also noticed that she began to have slight vaginal bleeding which was continuous for two and one-half months but which stopped for two months thereafter. However, the last two weeks before admission, the slight bleeding reappeared ofi and on. During this time, she also experienced slight afternoon rise of temperature. She had had three pregnancies, the first two of which ended in full-term deliveries ten years and five years, respectively, before admission. The third pregnancy ended in a four Menstrual periods after the abortion were months’ abortion one year previous to admission. normal, the last one occurring one month before the onset of the slight continuous bleeding. Physical examination showed that she was fairly well nourished though rather thin. Lungs and heart were apparently normal. The abdomen showed a large, firm, painless, slightly movable, globular tumor reaching up to the level of the umbilicus, the size of a six months ’ pregnancy. On vaginal examination, one could feel a small cervix connected with the uterus which was flattened and pushed to the left and posterior fornices by the large firm mass. There was slight. pinkish discharge from the external OS. Red blood count, 3,900,OOO; white blood count, 9,650; polymorphonuclear leucocytes, 77 per cent; lymphocytes 23 per cent,. Urinalysis normal. Blood pressure 110/70. Because of the finding of a firm, solid painless mass in the abdomen which was independent but intimately connected with the uterus, our first impression was a large subperitoneal fibroid. We could not, however, reconcile the diagnosis of a subperitoneal fibroid and the rapid growth of the tumor, which was noticed only five months previous to admission. But we felt that perhaps the tumor had existed unnoticed for sometime. Because of the rapidity of the growth, we considered the possibility of a malignant, tumor of the ovary. Chorionepithelioma was considered, but was immediately dismissed because of the firm consistency of the tumor and because the uterus could be distinctly outlined as separate from it. The patient was, therefore, scheduled for.operation three days later. On that day, however, she had cough and fever. In the belief that she was suffering from influenza, she was treated for this condition and the operation was postponed. But the fever, which was irregular, did not abate. On the contrary, as the days advanced, it became higher. Moreover, the patient began to complain of abdominal pain, tympanism, nausea and vomiting. At this time, we thought that what we regarded as a tumor was perhaps an encapsulated abscess which now began to leak into the peritoneal cavity and which needed immediate laparotomy, which was done on Oct. 2, 1947, under local anesthesia. On making a small incision on the peritoneum, an encapsulated mass looking like a large endometrial cyst was found. Aspiration revealed bloody content. After enlarging the abdominal incision and trying to evacuate the contents, we encountered a bloody mass of many small, firm, loose pieces of tissue attached to the intestines, omentum, uterus and posterior parietal peritoneum. We then thought we were dealing with a malignant growth of the 1195
1196
ACORTA-SISON
Am. J. Obst. & Gynec. December. 1948
ovary. But further exploration showed that both ovaries were intact, only that they were cystic. Since most of the bleeding came from the fundus of the uterus, we quickly did 9 subtotal hysterectomy and double salpingo-oophorectomy. After evacuating as much of the growth as possible and putting a firm gauze packing against the oozing surfaces, the abdominal incision was closed in the usual manner. Iinfortunately, we could not give blood transfusion L’or lack of a donor or blood bank. We gave four units of plasma, before, during, and after the operation, and continuous venoclysis of glucose solution. The patient became conscious after the operation, but succumbed two hours afterwards. Examination of the hysterectomized uterus showed a raw eaten-up fundus from which issued friable strands looking as if they had been pulled upwards. Sagittal section of the ntrrus showetl that the endometrium was clean without any trace of the growth. Both ovaries haJ bpen convrlted into corpus luteulrl psts 11~ sizca of a goose egg.
Autopsy revealed two more handfuls of growth attached to the intestines, omentum, and The lower lobe of the right lung showed a small focus of posterior pzrietal peritoneum. metastasis of the growth. Biopsy of the growth found in the lungs and abdominal cavity ~11o~ed syneytinm and Langhans (*ells with a predominance of the latter in some portions and of’ t.lu: former in other parts. C’omment:-Apparently, the contlit,ion begau as a myometrial chorionepithelioma which later extended to the right broad ligament and which rapidly grew in size. It was only in the last days, when the charionic cells had extended themselves beyond the confines of the broad ligament and serous surface of the uterus that internal bleeding, tympanism, abdominal pain supervened rapidly, threatening the life of the patient. Our inability to make preoperatively the correct diagnosis was due to the following: i 1) Because when first. seen, the size, consistency, and contour of the growth was suggestive more of uterine fibroid than of anyt,hing else. (2) The failure to associate the growth with the four months’ abortion which t,ook place seven months before she complained of bleeding. (,:‘,I The misinterpretation of the uterine bleeding that occurred later as part of the phenom(4) The fact that, she was in relatively good condition on admission, enon of uterine fibroma. in spite of the advanced condition of the growth. Because we erroneously thought chorionc~pithelioma was a remote possibility, no Friedman test was made, The reason the patient. here reported did not have early peritoneal bleeding, in spite of its being a myometrial growth that had gone beyond the uterus, is because the chorionic cells grew within the leaves
Volume Number
56 6
1197
CHORIONEPITHELIOMA
of the broad ligament which at first constituted itself as a firm capsule, giving shape and firm consistency to the growth in the same manner as happens in intraligamentous ovarian conditions or even pregnancy. The long interval of seven months that elapsed between her abortion and the occurrence From our experience with myometrial of the abnormal vaginal bleeding is not unusual. chorionepithelioma, in 55 per cent of the eight cases we had in 1942 to 1945, the vaginal bleeding did not manifest itself until from one year and two months to three years after the passage of the last product of conception which happened to be hydatidiform mole. Two of these cases were preoperatively diagnosed as cancer of the uterine corpus and two, because of symptoms of internal bleeding on admission, as ruptured tubal pregnancy. Had we seen the patient when she began to have continuous bleeding, had we felt the small mass in the lower abdomen, and associated such findings with her last abortion, we would have been able to diagnose her condition by the clinical method of diagnosis of uterine chorionepithelioma as first described by me.2 Even if our diagnosis then had been fibroma, she would have been saved by immediate laparotomy, which would have revealed the true condition of the uterus. If the correct diagnosis of abdominal chorionepithelioma had been made on her admission, what treatment should have been instituted? I believe the only hope for the patient then was x-ray treatment both for the abdominal and pulmonary growths. The
author
is greatly
indebted
to Dr.
Apelo,
who furnished
the photograph
of the uterus.
References 1. Aeosta-Sison, Early 2. Acosta-Sison,
H.: “Dangers of Myometrial Chorionepithelioma Caused by Failure of Diagnosis, ” J. Philippine College of Surgeons III: No. 1, Jan.-Feb., 1938. H., and Espinola, N.: AM. J. OBST. & GYNEC. 42: 878,1941.