Neonatal choriocarcinoma of liver

Intraplacental Gestational Neoplasms: A Review of Clinically Relevant Diagnostically Challenging Lesions

CONTEXT.—

Case studies reporting intraplacental choriocarcinoma (IPC) and intraplacental "chorangiocarcinoma" have recently increased, with IPC also represented in molecular analyses of gestational trophoblastic neoplasms.

OBJECTIVE.—

To provide an overview of 2 intraplacental neoplastic lesions that can have a significant impact on both mother and fetus/infant, focusing on diagnostic characteristics, and ancillary and molecular tools that support diagnosis, determine prognosis, and further elucidate the nature of these lesions.

DATA SOURCES.—

Data were compiled from a PubMed literature review that included diagnostic and additional keywords within the scope of study for gestational choriocarcinoma in general. Illustrative cases were retrieved from the pathology archives at Michigan Medicine, including the consultation files of the author.

CONCLUSIONS.—

Intraplacental gestational tumors exist along the spectrum of benign (chorangioma) to aggressive malignant (choriocarcinoma) neoplasms with a high potential for metastasis. Although most gestational choriocarcinomas follow complete hydatidiform mole, 20% to 25% occur in association with normal intrauterine gestations, including rare cases in which they are detected within the placenta (IPC). IPCs range from asymptomatic to widely metastatic, with metastases possible even when only microscopic IPCs are present. A second, even less common lesion, variably called "chorangiocarcinoma" and chorangioma with atypical trophoblast proliferation, is also reviewed. The incidence of these lesions is likely to be underestimated. Heightened suspicion and more liberal placental sampling, particularly when specific clinical features are present, may result in higher detection. Enhanced detection to provide the earliest intervention for both mother and infant may improve prognosis, particularly for asymptomatic disease that may later present with metastasis.

Simultaneous Occurrence of Choriocarcinoma in an Infant and Mother

Infantile choriocarcinoma is an extremely rare disease. We present a case study of a 1-month-old male with choriocarcinoma diagnosed simultaneously with his mother. On admission to hospital, the disease was very advanced and massive progression and multi-organ failure caused the death of the patient despite the implemented treatment. It was too late to save the child’s life, but early enough to save his mother. The authors believe that the serum levels of hCG should be determined in every newborn with anemia and liver tumor, especially when the mother has a positive history of miscarriage.

Primary choriocarcinoma of the liver: a clinicopathological study of five cases in males

Primary choriocarcinomas of the liver are rare. Previous reported cases were mostly in infants with only rare adult cases. Here, we presented five adult cases. The patients were all males, with an average age of 41.6 years (from 36 to 48 years). Clinical presentations included right upper abdominal pain or abdominal distension. All patients presented with a large hepatic mass on ultrasonography that measured 11 cm on average in the greatest diameter. Elevated serum human chorionic gonadotropin (HCG) levels were noted in all cases. At presentation, the tumor was confined to the liver in two patients and therefore surgically resected. The other three patients presented with extrahepatic metastases on imaging study and therefore only received chemotherapy. All five patients died from the tumor within 2 to 8 months. Autopsy was performed for all five cases. The autopsy confirmed that the choriocarcinoma was confined to the liver in two surgically resected cases. The other three patients had metastatic choriocarcinoma in the lung (two patients), peritoneum (one patient), adrenal glands (one patient), and brain (one patient). None of the patients had any evidence of a testicular tumor or scar after examination of the entirely submitted testes. No tumor was observed in central nervous system, mediastinum, or other organs other than described above. Grossly, the primary tumors were large, soft, hemorrhagic, and with foci of necrosis. Histologically, the tumors were composed of mononucleated trophoblastic cells with round nuclei, clear cytoplasm, and prominent nucleoli admixed with large, multinucleated syncytiotrophoblastic cells. Immunohistochemically, tumor cells were strongly positive for keratin, HCG, and focally positive for human placental lactogen. Ki-67 proliferation index was high (mean 75%) in the mononucleated trophoblastic cells. Our series is the largest one to document primary hepatic choriocarcinoma in adults. Although these tumors are rare, they behave in a very aggressive fashion.

Treatment of infantile choriocarcinoma of the liver

Primary choriocarcinoma of the liver is an extremely rare childhood malignancy frequently associated with clinical instability at initial presentation. It often mimics other benign and malignant childhood liver tumors. Prompt diagnosis and initiation of treatment are necessary to attain a successful outcome. We describe a critically ill infant with metastatic choriocarcinoma whose diagnosis was based on radiographic and tumor marker findings, without an initial biopsy, and her successful management with neo-adjuvant chemotherapy and delayed surgery. She is currently in continuous remission 24 months from diagnosis.

[Infantile choriocarcinoma: an uncommon and curable tumor]

Choriocarcinoma is a malignant growth of trophoblastic cells characterized by secretion of human chorionic gonadotropin (hCG). Infantile choriocarcinoma is a very rare tumor, which is a complication of gestational choriocarcinoma and usually had very poor prognosis before chemotherapy was used. We report 1 new case as well as a review of the literature since 1945. Our case report describes the successful treatment by chemotherapy of a newborn with cerebral metastasis. Several features are important: Infantile choriocarcinoma occurs in infants aged 0 to 6 months. Anemia, hepatomegaly and hemorrhagic syndromes are the main symptoms with sometimes cerebral, cutaneous or ear-nose and throat localisations. But diagnosis can be difficult when clinical symptoms are poor. The main diagnostic criterion is a very high plasmatic or urinary level of hCG or beta-hCG in the newborn. Histological pattern is not mandatory for diagnosis. Thoracoabdominal CT scan and cerebral MRI are necessary to find metastases. Recommended treatment is chemotherapy and surgery is discussed when a tumoral residue remains. Post-treatment surveillance is based on clinical and radiological examination as well as negativation of beta-hCG. Choriocarcinoma occurring simultaneously in mother and child have been reported. Therefore it is necessary to assay maternal serum beta-hCG when infantile choriocarcinoma is disclosed and to assay serum beta-hCG in the newborn when the mother has gestational choriocarcinoma. Infantile choriocarcinoma is a very chemosensitive tumor and is thereby potentially curable. Early diagnosis is the most important prognostic factor.

Intraplacental choriocarcinoma: experience from a tertiary referral center and relationship with infantile choriocarcinoma

The development of persistent gestational trophoblastic disease following an apparently uncomplicated term pregnancy is well-recognized; however, reports of confirmed intraplacental choriocarcinoma are rare. We report four cases of histologically reviewed intraplacental choriocarcinoma occurring in third-trimester pregnancies from the files of a regional trophoblastic disease unit. In all cases, macroscopic examination of the placenta appeared unremarkable, with small nondescript lesions being identified, thought to be fresh infarcts or intervillus thrombi. Histological examination demonstrated the presence of focal intraplacental choriocarcinoma. Review of the literature demonstrates primary intraplacental choriocarcinoma rarely may be associated with obstetric complications such as intrauterine death or fetal distress. But in most cases, the disease is initially asymptomatic, the diagnosis only being made following histopathological placental examination for other indications. Intraplacental choriocarcinoma may therefore manifest as a spectrum of clinical disease ranging from an incidental lesion diagnosed on placental pathological examination with no adverse effects on mother or baby, through to metastatic maternal disease that is present in about half of the cases, to disseminated fatal infantile choriocarcinoma.

Germ cell tumor-like neoplasms occurring outside the anatomic midline

Most germ cell tumors occur in the gonads or in extragonadal sites in the anatomic midline; this article reviews tumors with similar or identical histologic features that arise in other topographic locations. Such lesions often represent the presence of "germ cell-like" or "germinal" components in what is otherwise recognized as a somatic neoplasm; however, they may also occur in pure form. The morphologic and immunohistochemical features of these proliferations are reviewed, according to the types of germ cell tumors that they recapitulate.

Malignant retroperitoneal and abdominal germ cell tumors: an intergroup study

BACKGROUND/PURPOSE

This randomized study examined survival (S) and event-free survival (EFS) rates using high-or standard-dose cisplatin-based combination chemotherapy and surgical resection for this subset of germ cell tumors.

METHODS

Twenty-six of 317 patients enrolled on the POG 9049/COG 8882 intergroup study for malignant germ cell tumors had abdomen or retroperitoneum as the primary site. Twenty-five of 26 were eligible for inclusion (n = 25). Patients had biopsy or resection at diagnosis and randomization to chemotherapy including etoposide, bleomycin, and either standard-dose (PEB) or high-dose cisplatin (HDPEB). In patients with initial biopsy, delayed resection was planned.

RESULTS

Median age was 26 months. There were 14 girls and 11 boys. There were 3 stage I to II, 5 stage III, and 17 stage IV patients. Surgical management included primary resection in 5, resection after chemotherapy in 13, and biopsy or partial resection in 7 patients. Overall 6-year EFS rate was 82.8% +/- 10.9%, and 6-year survival rate was 87.6% +/- 9.3%. By group, 6-year survival rate was 90.0% +/- 11.6% for PEB and 85.7 +/- 14.5% for HDPEB. Deaths include one from sepsis, one from malignant tumor progression, and one from bulky disease caused by benign components despite response of the malignant elements to chemotherapy.

CONCLUSIONS

Malignant germ cell tumors arising in the abdomen and retroperitoneum have an excellent prognosis despite advanced stage in most children. Aggressive resection need not be undertaken at diagnosis, but a concerted attempt at complete surgical removal after chemotherapy is important to distinguish viable tumor from necrotic tumor or benign elements that will not benefit from further chemotherapy.

Disseminated choriocarcinoma in infancy is curable by chemotherapy and delayed tumour resection

Infantile choriocarcinoma has a poor prognosis with only 2 surviving children reported in the literature. 2 additional successfully treated children are presented. 2 infants (age 3 and 4 months at diagnosis) suffering from rapidly progressive choriocarcinoma with widespread haematogenous metastases involving the liver were treated according to the cooperative germ cell tumour treatment protocol (MAKEI 96) of the German Society of Pediatric Oncology and Hematology (GPOH). PEI-chemotherapy (cisplatin, etoposide, ifosfamide; no ifosfamide before the age of 4 months) was combined with delayed tumour resection. Treatment resulted in sustained remission in both children (event-free survival 42 and 40 months). Interphase fluorescent in situ hybridisation (FISH) analysis of the paraffin-embedded tumour sample from case one revealed four to eight copies of chromosomes X, 1 and 17 and two Y chromosomes. Hybridisation with sub-telomere and centromere specific probes for chromosome 1 displayed an imbalance between the short and long arms of chromosome 1. In the tumour cells from case 2, only a polysomy of chromosome X could be proven, other aberrations were not analysed in this case for technical reasons.

Effective treatment of infantile choriocarcinoma in the liver with chemotherapy and surgical resection: a case report

Infantile choriocarcinoma of the liver is an extremely rare entity, and outcome has been fatal in almost all published cases. To the authors' knowledge, this is the first report on successful treatment with preoperative chemotherapy. A 10-week-old girl presented with a large liver tumor, ovarian cysts, cardiac insufficiency, progressive hemolytic anemia, and thrombocytopenia. Ultrasound scan and magnetic resonance tomography (MRT) showed the typical pattern of infantile hemangioendothelioma. An emergency laparotomy was performed because of increasing cardiac insufficiency with ligation of the right hepatic artery, tumor biopsy, and subtotal resection of the ovarian cysts. Histology findings showed a choriocarcinoma of the liver and corpus luteum cysts of the ovaries. Serum beta-human chorionic gonadotropin (beta-HCG) was elevated to 1.600.00 U/L. Chemotherapy was initiated with etoposide and cisplatin. When x-ray examination showed development of lung metastases, chemotherapy was intensified with etoposide, cisplatin, and ifosfamid according to the German Study Group of Extracranial Nontesticular Malignant Germ Cell Tumors in Childhood and Adolescence (MAKEI-96). Serum beta-HCG levels decreased further, ultrasound examination showed significant tumor reduction, and pulmonal metastasis could no longer be found in chest x-rays. After the fourth course, a complete tumor resection was achieved by an extended right hemihepatectomy with adjuvant chemotherapy being administered after the operation. The child has been in complete remission for 22 months. The authors' experience shows that chemotherapy is effective for preoperative tumor reduction.

Intraplacental choriocarcinoma associated with viable pregnancy: pathologic features and implications for the mother and infant

Choriocarcinoma arising in the placenta, or intraplacental choriocarcinoma, has seldom been reported, particularly in the absence of maternal metastases. Reluctance to diagnose choriocarcinoma in the presence of chorionic villi can delay diagnosis; however, timely diagnosis of choriocarcinoma is prognostically important, both for the mother and infant. We report the clinicopathologic findings in five mothers and infants in whom choriocarcinoma was identified in the placenta. None of the mothers had a history of gestational trophoblastic disease in previous pregnancies. Three placentas were similar with a single small lesion grossly suggesting a small infarct; microscopically these consisted of infarcted areas surrounded by choriocarcinoma. These three mothers were unusual in that none had metastatic choriocarcinoma; two were treated with chemotherapy and remained disease-free; the third was lost to follow-up shortly following delivery. The remaining two mothers had known pulmonary metastases at time of delivery. One of these latter two placentas contained a large marginal lesion microscopically identified as choriocarcinoma. The fifth placenta had rare microscopic foci of choriocarcinoma, and sheets of necrotic choriocarcinoma were identified in "blood clot" submitted with the placenta. In four of the five cases the choriocarcinoma appeared to be arising from otherwise normal chorionic villi, and in no case was there invasion of the villous stroma. All of the infants survived, and none had evidence of choriocarcinoma. These cases support the concept that choriocarcinoma associated with otherwise normal pregnancy arises in the placenta and may be more common than reported.

Simultaneous choriocarcinoma in mother and newborn infant

A male infant, born following an uncomplicated pregnancy, was severely anaemic at birth following significant foeto-maternal haemorrhage. At three weeks of age a tumour was found in the liver with evidence of metastatic disease in the lungs. The infant died before treatment could be started. Postmortem revealed choriocarcinoma which led to subsequent diagnosis in the mother who also had pulmonary metastases. The mother has been successfully treated. The case is described in detail and followed by a discussion and a literature review of reported cases of simultaneous choriocarcinoma in infant and mother.