TROPHOBLASTIC DISEASE

From Big Medical Encyclopedia

TROFOBLASTYCHESKY DISEASE

(Greek trophe food, food + blas-tos a sprout, a germ) — the disease caused by disturbances of development and growth of a trophoblast.

Main forms T. the syncytial endometritis, a vesical drift (see) and a horionepite-lioma are.

T. is a frequent disease of women in the countries of Southeast Asia and islands of the Pacific Ocean and rather seldom meets in the European countries and the USA.

The etiology is not found out. There are two main theories of emergence of T. It agrees the first it is caused by pathology of fetal egg. The second theory explains an origin of a disease pathological, including hormonal, with changes of a maternal organism and snizheni-ekhm its protective forces. A certain value in an etiology of T. have features of the immune status of sexual partners, e.g., it is established that the horionepitelioma arises more often when the woman has a blood group of A (P), and the man 0 (I).

Syncytial endometritis — a high-quality form T., edges meets at early stages of development of fetal egg, and also after abortions and childbirth. A wedge, manifestations, as a rule, are absent. The diagnosis can be established only with the help gistol. researches of scraping from a cavity of the uterus, at Krom in the field of the placental platform (see) find a massive invasion of syncytial elements of chorion in mucous and muscular covers of a uterus with perifocal inflammatory infiltration (tsvetn. tab., Art. 368, fig. 5). The differential diagnosis is carried out from a horionepite-liomy uterus: at a syncytial endometritis there are no signs of an anaplaziya of cells, the centers of a necrosis and hemorrhage in surrounding fabrics do not come to light. Treatment is limited to a scraping of a mucous membrane of a uterus (see the Scraping). Forecast favorable.

Horionepitelioma (synonym: horio-

a carcinoma, chorionepithelioma malignum, blastoma deciduochoriocel-lulare, deciduoma, carcinoma sero-tinale) — the malignant tumor developing from cells of a trophoblast (see). Emergence polecats-onepiteliomy is, as a rule, connected with normal or patol. beremen-


Fig. 1. Macrodrug of a uterus at chorion-epitel to an ioma (the cavity of the uterus is opened): the cavity of the uterus is filled with exophytic tumoral formation of dark color.

nostyo. In most cases (50%) it is preceded by a vesical drift, in 25% — normal childbirth and in 25% — abortion or an extrauterine pregnancy. Horionepitelioma develops hl. obr. at multipara women, is more often at the age of 20 — 35 years. In rare instances the horionepitelioma arises in a teratoma (see) an ovary at girls and in a small egg at men.

More often the horionepitelioma is localized in a body of the womb, is more rare in the field of pathological implantation of fetal egg in a fallopian (uterine) pipe, an ovary or in an abdominal cavity (an ectopic horionepitelioma). Macroscopically the tumor has an appearance of a spongy soft node of bluish-crimson color. With an exophytic growth the tumor acts in a cavity of the uterus (fig. 1), at endophytic — is implemented into thickness of a myometrium up to a serous cover of a uterus. In rare instances the tumor is located in the thickness of a wall of a uterus (intramuralno) or has an appearance of the multiple centers in a body and at the same time in a neck of uterus.

Microscopically fabric of a tumor is similar to a syntrophoblast and a cytotrophoblast (see the Trophoblast), consists of Langkhans's cells (a polygonal form with the light cytoplasm containing a glycogen and puzyrkovidny kernels, it is frequent with figures of mitoses) and syncytial elements (tsvetn. tab., Art. 368, fig. 6 and 7). The ratio of components of a tumor can be various: the typiform is characterized by existence of both types of cells in equal ratios, at an atypical form of a horionepitelioma Langkhans's cells or syncytial elements prevail. Horionepitelioma does not contain fibers of chorion, in it there are no stroma and own blood vessels; an invasion of cells of a tumor in surrounding


Fig. 2. The roentgenogram of a thorax at metastasises of a horionepitelioma in lungs (a direct projection): multiple round shadows of metastasises are visible.

fabric is not followed by any cellular or vascular reaction. In fabric of a tumor and on its periphery extensive sites of a necrosis and the field of hemorrhages meet (tsvetn. tab., Art. 368, fig. 8).

Innidiation (see) preferential hematogenous — in lungs, a vagina, a liver, a brain, is more rare in intestines, nights, a spleen.

Patients note emergence from a genital tract of the bloody allocations (in the beginning moderated, then amplifying) after the former pregnancy and is especially frequent if in the anamnesis there was a vesical drift. These allocations are caused by destruction of blood vessels in the field of a tumor or its metastasises in a vagina. At an arrangement of a horionepitelioma in the thickness of a wall of a uterus, a fallopian pipe and destruction of a serous cover there can be plentiful vnutribryutpny bleeding (see). Bleeding in an abdominal cavity can arise also from metastatic nodes in a liver and intestines. At a ho-rionenitelioma of a fallopian pipe strong colicy pains in the bottom of a stomach are noted that reminds a wedge, a picture of an extrauterine pregnancy (see). As a result of bleedings and intoxication quickly progressing anemia develops (see), in connection with a necrosis and infection of nodes of a horionepitelioma the feverish state can be observed. In some cases increase in mammary glands, pigmentation of a peripapillary areola is noted (a peripapillary circle of a mammary gland, T.) and release of colostrum.

At development of metastasises there are symptoms caused by their localization. So, at metastatic damage of lungs appear cough with a phlegm and thorax pains; a brain — headaches, vomiting, a hemiplegia and others nevrol. symptoms; bodies went. - kish. a path — nausea, vomiting, abdominal pains, went. - kish. bleedings.

Pr and survey of a neck of uterus by means of mirrors it is possible to find cyanosis of a mucous membrane of a vagina and neck of uterus, and also metastasises of a tumor in a vagina in the form of dark red eminences and small knots with a characteristic gray shade in case of approach of the expressed necrotic changes. The body of the womb is increased to respectively eight and more weeks of pregnancy, has a softish consistence. At a bimanual research (see. A gynecologic research) define a pulsation of uterine vessels and the increased ovaries. Approximately in 50% of cases teka-l to Utah and new cysts of ovaries are found (see Ovaries).

The diagnosis of a horionepitelioma is based on a wedge, data, identification of the chorionic gonadotrophin produced by cells of a tumor (see) in urine and trophoblastic (a 3-liioiroteina (see Lipoproteids) in blood serum, data gistol. researches of scraping from a cavity of the uterus and results rentgenol. researches. For identification of a chorionic gonadotrophin use biol. reactions (see Ashgey-m — Tsoideka reaction, Galli - Mai - nini reaction, Friedman reaction) and immunol. methods. The caption of hormone allows to judge quantitative contents him in urine and blood, and its definition in urine of women, at to-rykh after the delivery or abortion bloody allocations from a genital tract did not stop or arose, is of great importance for early recognition of a horionepitelioma. At the expressed necrosis of a tumor the maintenance of a chorionic gonadotrophin in urine can be low.

The diagnosis of a horionepitelioma based on gistol. a research of scraping, it is not always reliable as similar pictures can be observed also after abortion. Therefore the presumable diagnosis at gistol. a research it has to be confirmed with results of definition of a chorionic gonadotrophin. Negative or doubtful takes gistol. researches of scraping from a cavity of the uterus do not give the grounds to completely exclude a possibility of a horionepitelioma.

Tsitol. the research did not find broad application in diagnosis of a horionepitelioma of a uterus since detection of elements of a tumor in smears is complicated in view of a frequent necrosis of its surface and bloody allocations from a uterus.

Rentgenol. the research of a thorax allows to reveal metastasises of a horionepitelioma in easy (fig. 2). At a pelvic angiography the area of defeat thanks to its plentiful vascularization clearly is visible (see fig.

to St. Pelvic angiography, t. 24, Art. 47). By means of a gisterografiya find nodes of a horionepitelioma in a uterus at their submucosal arrangement (see Metrosaljpingogra-fiya). On gisterogramma the uterus is increased, contours of its walls uneven, corroded, with defects of filling, a contrast agent gets into depth of a myometrium.

The differential diagnosis is carried out with a syncytial endometritis (see above), a placental polyp (see), pregnancy, and chorion epithelioma of a fallopian pipe is differentiated with extrauterine (pipe) pregnancy (see. Extrauterine pregnancy). In differential diagnosis of metastatichesko-whom of damage of lungs at polecats-onepiteliome and a pulmonary tuberculosis an important role is played by data of the anamnesis and definition in urine of a chorionic gonadotrophin.

The treatment combined. In a crust, time use treatment by antineoplastic means more often (see), a cut in some cases combine with operational treatment or radiation therapy. From among antineoplastic means apply antimetabolites (a methotrexate, merkaitopu-rin), antineoplastic antibiotics (rubomitsin, Dactinomycinum, Olivomycinum, adriamycin, bleomycin), drugs of a plant origin (vinblastine, Vincristinum), etc. Treatment spend by any one antineoplastic means at a horionepitelioma of a uterus lasting disease less than 6 months and the sizes of a uterus no more than 8 weeks of pregnancy. Lasting disease over 6 months, emergence of a horionepitelioma after the delivery, inefficiencies of treatment by one drug, and also in the presence of metastasises use various combinations of antineoplastic means. In All-Union oncological scientific center of the USSR Academy of Medical Sciences are developed and two main schemes of treatment of a horionepitelioma are used by several antineoplastic means: 1) methotrexate + Dactinomycinum + vinblastine; 2) methotrexate + rubomitsin + Vincristinum. Duration of one course of treatment of 2 weeks, breaks between courses 2 —

3 weeks. After disappearance a wedge, displays of a disease conduct two more preventive courses of treatment, further carry out regular observation within

2 years.

Operational treatment — a hysterectomy (see) with appendages or without them — it is shown at the sizes of a uterus more than 12 weeks of pregnancy, plentiful uterine bleedings, threat of perforation of a wall of a uterus, and also at inefficiency of treatment by antineoplastic means. As an additional method of treatment radiation therapy can be used (see), to-ruyu apply at metastasises chorion-epitel of an ioma in the parameter of l ny cellulose (a remote gamma therapy) and in a vagina (intracavitary radiation).

The forecast depends on a form of a tumor, duration of a disease and timeliness of the begun treatment. According to All-Union oncological scientific center of the USSR Academy of Medical Sciences (1982), at a horionepitelioma of a uterus without metastasises practical treatment can be reached at 91% of patients, and at metastasises in lungs — at 57%. At the same time at women in the reproductive period with the kept uterus in the subsequent normal pregnancy can develop. Cases of spontaneous disappearance both the main node of a tumor, and its metastasises are known.

Prevention chorus you ionepit l of an ioma the hl consists. obr. in careful observation and preventive treatment of the patients who transferred a vesical drift (see. Vesical drift, prevention).

Bibliogr; Grigorova T. M. Trophoblastic tumors of a uterus, diagnostic problems, treatment and forecast, Akush. and ginek, JSIa 12, page 40, 1979; D and in and d e the Tax Code about A. A. Horionepiteliom, Kiev, 1973; Clinical oncology, under the editorship of H. N. Blochina and B. E. Peterson, t. 2, page 252, M., 1979; Kozachenko V. P., etc. Diagnosis and treatment of trophoblastic tumors of a uterus, Vopr. onkol., t. 28, No. 5 * page 97, 1982; Nechayeva I. D. and Dilman V. M. Trophoblastic disease, L., 1976, bibliogr.; N about-vikova L. A. and Grigorov of T. M. Horionepiteliom of a uterus, L., 1968, bibliogr.; Pathoanatomical diagnosis of tumors of the person, under the editorship of N. A. Krayevsky, etc., page 267, M., 1982; Poulsen G. E. and Taylor K. U. Histologic classification of tumors of a female sexual path, lane with English, Geneva, 1981; Savinova V. F. and Barinov of V. V. Himioterapiya of metastasises of a horponepitelioma of a uterus in lungs, Akush. and ginek., No. 12, page 43, 1979; Savinova V. F. and L e with and to the island and T, Century. The long-term results of treatment of patients with trophoblastic tumors at the kept uterus, in the same place, No. 12, page 24, I97g. in a g s h a w e To. D. Choriocarcinoma, clinical biology of the tropho-blast and its tumors, Baltimore, 1969; Hertz R. Choriocarcinoma and related gestational trophoblastic tumors in women, N. Y, 1978; Holland J.

F. a. Frei E Cancer medicine, p. 2014, Philadelphia, 1982. V. P. Kozachenko.

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