Primary gestational choriocarcinoma of the uterine cervix. Report of a case and review of the literature

Primary cesarean scar choriocarcinoma: A case series and literature review

OBJECTIVES

To provide clinical guidance for early diagnosis and effective management of primary cesarean scar choriocarcinoma, which is an extremely rare but highly malignant trophoblastic tumor.

METHODS

This retrospective case series summarized the clinical courses of seven patients diagnosed with cesarean scar choriocarcinoma.

RESULTS

We identified two patients in our institution with cesarean scar choriocarcinoma. In addition, details of the previous five patients were extracted from databases and analyzed to provide more clinical information. The seven patients had an average age of 31.14 years, their tumor sizes ranged from 2.0 to 6.5 cm, and their pretreatment serum β-human chorionic gonadotropin (β-hCG) levels ranged from 3664 to 312 468 mIU/mL. All the patients were categorized as having FIGO Stage I disease, with four patients at low risk and three at high risk. Six of the seven were misdiagnosed with ectopic pregnancy before pathologic examination.

CONCLUSIONS

Clinicians should pay attention to masses in cesarean scar and to continuous elevation of serum β-hCG levels after treatment. When cesarean scar choriocarcinoma is suspected, diagnostic surgery can be chosen for tentative treatment and pathologic sampling. Salvage EMA-CO chemotherapy (etoposide, actinomycin D, methotrexate, cyclophosphamide and vincristine) should be performed as early as possible to prevent metastasis and recurrence after pathologic diagnosis.

Identification and treatment of primary cervical gestational trophoblastic neoplasia: a retrospective study of 13 patients and literature review

Background

Primary cervical gestational trophoblastic neoplasias (GTNs) are extremely rare ectopic GTNs. Such lesions are difficult to diagnose clinically because of their rarity, with abnormal vaginal bleeding of a non-specific cause being the most common symptom. To that end, this retrospective study aimed to identify the clinical characteristics of cervical GTN and to explore diagnostic and therapeutic strategies.

Results

Thirteen patients diagnosed with primary cervical GTN at the Department of Gynecology, Peking Union Medical College Hospital, Beijing, China, between June 1, 1988 and May 31, 2020 were included in the study. All patients had irregular vaginal bleeding, including six who presented with massive bleeding. Seven patients (53.8%) were initially misdiagnosed with a cervical pregnancy. All patients received chemotherapy; 11 (84.6%) also underwent hysterectomy because of chemoresistant lesions or uncontrolled bleeding. All patients achieved complete remission; however, two women (15.4%) experienced a relapse during the median follow-up period of 35 months. A comprehensive review of English-language literature published between 1980 and 2020 identified 22 case reports encompassing 27 patients. The definitive diagnosis was achieved via pathology in 26 of them (96.3%), and hysterectomy was performed in 21 (77.8%).

Conclusions

Owing to its rarity and nonspecific symptoms, the diagnosis of primary cervical GTN is challenging and often relies on pathology. The combination of chemotherapy and hysterectomy is the main therapeutic strategy for this disease.

Gestational Trophoblastic Tumors: A Timely Review of Diagnostic Pathology

CONTEXT.—

Gestational trophoblastic tumors include 3 distinct entities: gestational choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Accurate diagnosis is important for clinical management of the patient.

OBJECTIVE.—

To review clinical features and pathologic diagnosis of gestational trophoblastic tumors.

DATA SOURCES.—

Literature and personal experience are the sources for this study.

CONCLUSIONS.—

Trophoblastic tumors are rare encounters in modern medicine, as a result of clinical practice of molar surveillance programs and early chemotherapeutic intervention for persistent gestational trophoblastic neoplasia. Diagnostic recognition of these tumors requires a high index of suspicion, awareness of their histologic characteristics, and appropriate application of immunohistochemical and molecular biomarkers. Recent attention has been given to a few precursor lesions of gestational trophoblastic tumors, including early/in situ choriocarcinoma and atypical placental site nodule.

Unusual clinical presentations of choriocarcinoma: A systematic review of case reports

Choriocarcinoma (CC) is a highly malignant tumor originating in the trophoblastic tissue. The clinical presentation of CC is so much varied that every case may be one of its kinds and thus can be a diagnostic challenge. Numerous case reports have been published in various journals regarding the unusual clinical presentations of this cancer. Therefore, we conducted a systematic review of all case reports in English language on gestational CC published in PubMed-indexed journals from 1998 to 2015. The main aim was to provide a summary and critical analysis of all the data and evidence published regarding the atypical clinical presentations of CC in recent years. In total, 121 case reports pertaining to unusual clinical manifestations of gestational CC were analyzed. The age of patients in whom cases were reported ranged from 17 to 67 years, and the time period between the index pregnancy and development of CC varied from 4 weeks to as long as 25 years. Cardiopulmonary complaints (20.66%) followed by gastrointestinal (18.43%) and central nervous system manifestations (17.67%) were found to be the most common. Through this review, the authors have made an attempt to discuss various manifestations with which a patient with gestational CC can present to clinician so that early diagnosis and timely management can be initiated, thus improving clinical prognosis.

Primary cervical choriocarcinoma during viable intrauterine pregnancy

A 31-year-old multigravida woman at 27 weeks' gestation was admitted with vaginal bleeding and a hypervascular mass near the cervix on ultrasonography. After discharge with improvement, she was readmitted the next day for uncontrolled, heavy vaginal bleeding and underwent emergency cesarean section at 29 weeks' gestation. A 3-cm friable mass found near the cervix was removed surgically; this lesion was shown to be primary cervical choriocarcinoma. On the 17th postoperative day the patient underwent total abdominal hysterectomy with preservation of both ovaries and biopsy was performed on the right ovary. The International Federation of Gynecology and Obstetrics (FIGO) stage was I and her World Health Organization prognostic score was 9, representing high risk. The patient received three rounds of chemotherapy until achieving three consecutive normal human chorionic gonadotropin levels with two additional courses to address risk of relapse. DNA genotyping on short tandem repeat polymorphism confirmed the gestational choriocarcinoma.

Caesarean scar choriocarcinoma: a case report and review of the literature

OBJECTIVE

To report the clinical characteristics, pathologic findings and treatments of a patient with a Caesarean scar choriocarcinoma.

PATIENT HISTORY

A 22-year-old woman had a diagnosis of primary gestational choriocarcinoma in a uterine Caesarean scar misdiagnosed as a normal Caesarean scar pregnancy. The patient underwent selective uterine artery embolization coupled with methotrexate arterial injection, along with dilatation and curettage of the uterine Caesarean scar. Finally, she received eight courses of multiagent chemotherapy. The reproductive function of the patient was preserved.

CONCLUSIONS

Primary gestational choriocarcinoma out of the uterine corpus is a rare disease. A Caesarean scar choriocarcinoma is an extremely unusual example of this entity because of its unique position. To the best of our knowledge, this is the first report of this phenomenon. Our experience and a literature review suggest that a clinical diagnosis of a primary gestational choriocarcinoma of the uterine Caesarean scar is difficult to make, and uterine artery embolization is beneficial to prevent massive bleeding before curettage.

Treatment of gestational choriocarcinoma and massive ascites by hypothermic intraperitoneal perfusion chemotherapy guided by ultrasound followed by cytoreductive surgery

A 33-year-old woman with very poor health status was admitted to our hospital because she had experienced increasing abdominal distention for three months, CT examination showed a right ovarian tumor together with massive abdominal and pelvic fluid. The patient was first treated by continuous circulatory hypothermic intraperitoneal perfusion chemotherapy (HIPC) guided by B-mode ultrasound, followed by cytoreductive surgery (CRS) after her ascites was controlled and her health condition improved. She was diagnosed with gestational choriocarcinoma (GC) based on the pathological examination of the hysterectomy specimen. She is still alive with very good health today. We think it may be a good choice for a patient in very poor health with GC accompanied by massive ascites to perform HIPC guided by B-mode ultrasound firstly, followed by CRS when the ascites has relieved and the patient’s health has improved.

Uterine gestational choriocarcinoma developing after a long latent period in a postmenopausal woman: the value of DNA polymorphism studies

This article reports a uterine gestational choriocarcinoma arising in a 57-year-old woman with a long latent period of 22 years from the last known pregnancy. Diagnosis was made on an endometrial biopsy specimen, and given the age of the patient, the long latent period, and the limited sample, trophoblastic differentiation within an endometrial carcinoma was considered. The results of DNA polymorphism studies illustrated both paternal and maternal alleles within the tumor in equal amounts, confirming the neoplasm to be gestational in origin and to have originated from a nonmolar gestation. The report discusses the value of DNA polymorphism studies in distinguishing gestational from nongestational choriocarcinoma and from trophoblastic differentiation within a carcinoma.