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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 386-387

Surgical and medical management of choriocarcinoma


Department of Obstetric and Gyanacology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India

Date of Submission09-Oct-2019
Date of Decision17-Jul-2020
Date of Acceptance31-Dec-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Ashishkumar Bhatt
Room No. 8, Meghe Height Building No. 2, Datta Meghe Medical College Campus, Sawangi, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_149_19

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  Abstract 


Gestational choriocarcinoma is rare but highly malignant tumor of trophoblastic tissue. Although choriocarcinoma has a greater tendency to metastasize to various sites, it also has a very high cure rate. Our study emphasizes the case of choriocarcinoma developed after molar pregnancy which was treated successfully with the combination of surgery and chemotherapy.

Keywords: Choriocarcinoma, EMACO, molar pregnancy


How to cite this article:
Bhatt A. Surgical and medical management of choriocarcinoma. J Datta Meghe Inst Med Sci Univ 2021;16:386-7

How to cite this URL:
Bhatt A. Surgical and medical management of choriocarcinoma. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 9];16:386-7. Available from: http://www.journaldmims.com/text.asp?2021/16/2/386/328450




  Introduction Top


Choriocarcinoma is a rare form of malignant tumor of the trophoblastic tissue. Its incidence is highly uncommon constituting about 0.04% of the gestational trophoblastic disease (GTD)[1] but presents as highly aggressive malignant tumor. The risk of GTD is higher in older and multiparous women and in very young women.[2]

Gestational choriocarcinoma may follow any type of pregnancy and mostly is associated with coincident or antecedent pregnancy. It may result from abortion, full-term pregnancy, and molar pregnancy. The majority arise following a nonmolar pregnancy. Here is a case report of a young woman of choriocarcinoma presented after consecutive third abortion managed with surgery and chemotherapy.


  Case Report Top


A 21-year-old woman, gravida 3 with two abortions was admitted for bleeding per vaginum with 9 weeks of amenorrhea. Per abdominal examination showed a soft abdomen with no guarding, tenderness, or rigidity. Per speculum examination, the cervix was congested with minimal bleed and per vaginum examination suggestive of the uterine size of 8 weeks size and fornices were free. Per speculum examination revealed bleeding through os. The patient's ultrasound examination was suggestive of incomplete abortion. Sonography and Doppler of the pelvic region showed bulky uterus with fundal endometrial hyperechoic rounded lesion measuring 5.7 cm × 4.2 cm with significant vascularity. A significant thinning if the perifocal posterior myometrial wall extending to the subserosal peripheral plane was noted [Figure 1]. The adjacent parametrium appeared normal with the anterior wall relatively well maintained. Thinning of the lower endometrium was noted. There was no evidence of free fluid in the pelvis or adnexal mass. Both the ovaries appeared normal in size, shape, and follicular pattern. The pelvic sonography was suggestive of vesicular mole invading the posterior wall extending peripheral myometrial zone. The findings on the magnetic resonance imaging revealed enlarged, partially retroverted uterus with the large lesion in the fundal cavity appeared as an invasive mole invading fundal as well as the posterior wall of the uterus. No lymph node involvement was seen. Human chorionic gonadotropin (βhCG) titer was 110,000 mUI/ml. Imaging investigation of the chest, abdomen, and pelvis did not show any metastasis. These findings were consistent with molar pregnancy with no metastasis to adjacent organs or pelvic lymph nodes. Dilatation and curettage were done and the product of conception was sent for histopathology, the sections of which showed a malignant tumor composed of cluster of atypical cytotrophoblast separated by streaming sheets of syncytiotrophoblast, many mitotic figures, and cytologic atypia. Extensive areas of necrosis and hemorrhage were also seen. There was no lymphovascular emboli noted. These findings were consistent with choriocarcinoma. The patient was kept under observation and serial βhCG monitoring done, which reduced to 39,400 mIU/ml after 15 days of curettage. After the medical oncologist's consultation, EMACO regimen was started as a prophylactic treatment as the βHCG levels were high. After 1 cycle of treatment, βHCG decreased to 11,460 mUI/ml. The posttreatment hemoglobin was 8.3 g/dl as compared to her pretreatment hemoglobin of 10.2 g/dl, injection granulocyte colony-stimulating factor was given.
Figure 1: Ultrasonographic picture of vesicular mole in utero

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  Discussion Top


Choriocarcinoma also known as trophoblastic tumor is a rare form of cancer associated with molar pregnancy, ectopic pregnancy, miscarriage, or abortion. Although rare, it can rapidly invade and metastasize to other sites.

Our case presented with bleeding per vaginum clinically, molar pregnancy on ultrasound examination, high βHCG titer levels and histopathological findings of clusters of atypical cytotrophoblast separated by streaming sheets of syncytiotrophoblast, many mitotic figures, and cytologic atypia which are classic features of choriocarcinoma.[3]

Ultrasound has become the standard protocol in aiding in the diagnosis of suspected choriocarcinoma[4] which are further co-related with high titers of βHCG. Chest X-ray was taken to note any metastasis.

The main management for complete or partial moles is through surgical uterine evacuation (dilation and evacuation, suction curettage).[5] Hysterectomy can be a considerable option for patients who have completed childbearing.[6] As the patient in our case was young and nulliparous, it was necessary to preserve her future fertility, hence hysterectomy was contraindicated. Choriocarcinoma is very sensitive to chemotherapy and recent data from Charing Cross Hospital shows the EMACO regimen to be an effective treatment.[7] Therefore, a cycle of EMACO regimen was given to the patient as the βHCG levels remained elevated after dilatation and curettage. The patient recovered well with decrease in βHCG levels after chemotherapy.


  Conclusions Top


Our case report highlights the possibility of choriocarcinoma after any abortion. Early diagnosis with ultrasound and histopathological examination with timely surgical intervention and chemotherapy with EMACO, choriocarcinoma can be effectively treated. Early detection and treatment improves the outcome of choriocarcinoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sebire NJ, Lindsay I, Fisher RA, Seckl MJ. Intraplacental choriocarcinoma: Experience from a tertiary referral center and relationship with infantile choriocarcinoma. Fetal Pediatr Pathol 2005;24:21-9.  Back to cited text no. 1
    
2.
Sebire NJ, Foskett M, Fisher RA, Rees H, Seckl M, Newlands E. Risk of partial and complete hydatidiform molar pregnancy in relation to maternal age. BJOG 2002;109:99-102.  Back to cited text no. 2
    
3.
Brătilă E, Ionescu CA, Vlădescu CT, Cîrstoiu MM, Berceanu C. Gestational choriocarcinoma after term pregnancy: A case report. Rom J Morphol Embryol 2015;56:267-71.  Back to cited text no. 3
    
4.
Goldstein DP, Berkowitz RS. Current management of gestational trophoblastic neoplasia. Hematol Oncol Clin North Am 2012;26:111-31.  Back to cited text no. 4
    
5.
Lurain JR. Gestational trophoblastic disease I: Epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol 2010;203:531-9.  Back to cited text no. 5
    
6.
Gerstl B, Sullivan E, Vallejo M, Koch J, Johnson M, Wand H, et al. Reproductive outcomes following treatment for a gynecological cancer diagnosis: A systematic review. J Cancer Surviv 2019;13:269-81.  Back to cited text no. 6
    
7.
McGrath S, Short D, Harvey R, Schmid P, Savage PM, Seckl MJ. The management and outcome of women with post-hydatidiform mole 'low-risk'gestational trophoblastic neoplasia, but hCG levels in excess of 100 000 IU l − 1. Br J Cancer 2010;102:810.  Back to cited text no. 7
    


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