Incidental Placental Choriocarcinoma in a Term Pregnancy: A Case Report

Christopher Chung; Ming-Shian Kao; Deborah Gersell

Disclosures

J Med Case Reports 

In This Article

Discussion

We performed a medline search (1966 to 2008) using the keywords placenta, choriocarcinoma, and trophoblastic disease. We found 21 articles with 32 cases of placental choriocarcinoma in the English literature. Fourteen cases of choriocarcinoma were confined to the placenta with no evidence of dissemination to mother or infant; five of these 14 cases were incidentally identified in patients with normal pregnancies. To our knowledge, our case is the sixth of this type.

Choriocarcinoma in the placenta differs somewhat from those occurring elsewhere. The majority of placental choriocarcinomas appeared as poorly defined lesions macroscopically, and they are often interpreted as placental infarcts or intervillus thrombi. It is often only after metastatic symptoms occur in mother or infant that the placenta is resubmitted for further evaluation, and small lesions are identified microscopically. When recognized grossly, most placental choriocarcinomas have been described as yellow-white granular lesions thought to be infarcts. Microscopically, placental choriocarcinomas usually revealed areas in which the trophoblast is distributed as a mantle around villi with partial involvement and transition from normal trophoblast. This surface villous growth is often at the periphery of a central zone composed of necrotic, confluent trophoblast and villi explaining its gross resemblance to an infarct. Invasion of villous stroma has been described in rare cases.

Obstetrically, the majority of the reported cases had a normal prenatal course. Placental choriocarcinoma was often diagnosed after the mother developed symptoms of metastasis either antepartum or postpartum. The symptoms included vaginal bleeding, chest pain, and neurological signs such as seizures and stroke. In terms of maternal outcome, mothers who developed metastasis were often treated with chemotherapy which consisted of etoposide, methotrexate, actinomycin-D, cytoxan or vincristine. The response rate after chemotherapy is high; the majority of mothers were disease free after 1 year. Four mothers died of disease, but these 4 cases all occurred in the early 1980s.[1,2] Kodama et al reported a case where the mother underwent partial lobectomy after pulmonary lesions were identified in 1994.[3] Four cases of hysterectomy were reported by Brewer et al in 1981, Ollendorf in 1990, and Flam in 1996.[1,4,5] In mothers with no evidence of metastasis, only three of the 14 cases were treated with chemotherapy; the others were followed with serial serum hCG measurement until it dropped to zero during the post partum course. Multiple imaging modalities such as X-ray, CT scan and magnetic resonance imaging were often used to rule out metastasis. Our patient continued to have annual follow-up with the Gynecologic Oncology service after multiple studies to rule out metastasis in the first year post partum.

In terms of fetal outcome, ten cases resulted in either intrauterine demise or neonatal death. In 2006, Liu and Guo reported the only case in which an infant was successfully treated with chemotherapy after metastasis to jejunum and lungs was identified.[6] Most of the infants born showed no evidence of disease after 1 year.

Due to the potential fatal outcome of placental choriocarcinoma, the diagnosis should require careful evaluation of both mother and infant. Other clinical manifestations such as hyperthyroidism which is sometimes associated with high serum HCG should also be ruled out. Hyperemesis gravidarum is a common symptom in patients with hyperthyroidism. Serial serum beta hCGs and imaging studies should be employed to rule out metastasis. Maternal metastasis is very responsive to chemotherapy. Fetal metastasis is rare and usually fatal. In cases where placental choriocarcinoma is confined to the placenta without evidence of metastasis, only three of the 14 cases were treated with methotrexate chemotherapy, and the others were followed by serial beta hCG and imaging studies, all with excellent outcome. We believe in these cases, no chemotherapy is needed, providing serial beta hCG and imaging studies during postpartum follow up remain normal.

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