|Year : 2019 | Volume
| Issue : 2 | Page : 87-89
Tubal choriocarcinoma presenting as an ectopic pregnancy
Anita Kant1, Grishma Dhanesha1, Usha Gupta1, Amrita Kaul1, Divya Kant2
1 Department of Obstetrics and Gynecology, Asian Institute of Medical Sciences, Faridabad, Haryana, India
2 Department of Radiodiagnosis, Mahajan Imaging Centre, Gurgaon, Haryana, India
|Date of Submission||31-May-2019|
|Date of Acceptance||10-Dec-2019|
|Date of Web Publication||31-Jan-2020|
Dr. Anita Kant
Chairman and Head, Department of Obstetetrics and Gynecology, Asian Institute of Medical Sciences, Faridabad, Haryana
Source of Support: None, Conflict of Interest: None
Choriocarcinoma, a subtype of gestational trophoblastic disease, is a rare and aggressive neoplasm. It occurs due to neoplastic changes in the chorionic villi epithelium. Primary fallopian tube choriocarcinoma is extremely rare and commonly mistaken as ectopic pregnancy. We present a case of a 37-year-old female who presented with complaints of prolonged spotting per vaginum following an induced abortion. Ultrasound was suggestive of the right tubal ectopic pregnancy, and beta-human chorionic gonadotropin (BHCG) levels were remarkably high. The patient was taken for laparoscopy suspecting tubal ectopic pregnancy and right salpingectomy was done. Histopathology was suggestive choriocarcinoma of fallopian tube. Contrast enhanced CT scan of brain MRI pelvis, and chest X-ray showed no evidence of metastasis. Hence, the patient was managed with single-agent chemotherapy with injection methotrexate with leucovorin. The case highlights the importance of histopathological examination of tubal specimen in all patients presenting with tubal ectopic pregnancy and also the need to suspect a tubal choriocarcinoma in any patient presenting as ectopic pregnancy with high BHCG levels.
Keywords: Beta-human chorionic gonadotropin, chemotherapy, ectopic pregnancy, tubal choriocarcinoma
|How to cite this article:|
Kant A, Dhanesha G, Gupta U, Kaul A, Kant D. Tubal choriocarcinoma presenting as an ectopic pregnancy. Onco Fertil J 2019;2:87-9
| Introduction|| |
Choriocarcinoma, a subtype of gestational trophoblastic disease (GTD), is a rare and aggressive neoplasm. It occurs due to neoplastic changes in the chorionic villi epithelium. The gestational choriocarcinoma usually originates in uterus. The choriocarcinoma of the Fallopian tube More Details is an extremely rare entity. The choriocarcinoma associated with ectopic pregnancy is extremely rare and reported the incidence of ectopic tubal choriocarcinoma is approximately 1 in 1.6 million normal intrauterine pregnancies. A tubal choriocarcinoma can be mistaken for an ectopic pregnancy due to symptoms such as amenorrhea, increased beta-human chorionic gonadotropin (BHCG) levels, vaginal bleeding, and pelvic pain.
| Case Report|| |
A 37-year-old female, gravida 4, para 1, live 2, abortion 1, presented in gynecology outpatient department with complaints of spotting per vaginum since 18 days. She had an induced abortion at 1.5 months of amenorrhea on the basis of a positive urine pregnancy test, though the ultrasound had shown an empty uterine cavity and no adnexal mass. She bled for 2–3 days followed by spotting per vaginum for 15 days till she came to us. In the past, she had a cesarean section in 2014. In 2017, she had surgical MTP (dilatation and evacuation) in which perforation of uterus had led to pelvic abscess and sepsis requiring laparotomy. Her menstrual cycles were normal. On general examination, she was hemodynamically stable. The systemic examination was normal. On per abdominal examination, there was marked tenderness in lower abdomen. On per vaginum examination, the uterus was normal in size with tenderness in the right fornix. Serum BHCG was 186,633. Transvaginal ultrasound showed a right adnexal of 4.3 cm × 2.7 cm size with minimal free fluid. Laparoscopy was done which showed right-sided ruptured tubal ectopic pregnancy with hemoperitoneum. Right salpingectomy was done. The postoperative period was uneventful. The histopathology report showed choriocarcinoma in tubal pregnancy. Magnetic resonance imaging (MRI) brain, contrast-enhanced computed tomography pelvis, and chest X-ray showed no evidence of metastasis. According to the modified WHO scoring system for GTD, the patient was in low risk group. Hence, she was started with single-agent chemotherapy with intramuscular injection methotrexate (50 mg/m2) along with leucovorin on an 8-day alternate regimen. After 4 cycles of chemotherapy, her BHCG level was <2.
| Discussion|| |
GTD is a spectrum of disorders that arise from placental trophoblasts. Choriocarcinoma is one of the most aggressive forms of GTD. Tubal choriocarcinoma can be gestational or nongestational. About 25% of choriocarcinoma follow tubal or ectopic pregnancy, 25% are associated with preterm gestation and the remaining 50% arise from molar pregnancy. A tubal choriocarcinoma can be mistaken for an ectopic pregnancy because of its rarity, its presentation mimicking a routine tubal pregnancy, only a small mass available for histology and frequent lack of discriminating immunohistochemistry. Tubal choriocarcinoma can arise either from malignant transformation of tubal pregnancy or de novo without an ectopic pregnancy. Of reported cases of choriocarcinoma, majority present as ectopic pregnancy. Few cases may present following in vitro fertilization, in postmenopausal women or tubal choriocarcinoma with co-existent viable intrauterine pregnancy. The lungs, liver, brain, vagina, and digestive tract are common sites of metastasis. Histopathology is the gold standard for diagnosing choriocarcinoma. The typical features of choriocarcinoma consist of columns of trophoblastic cells without any villous structures and the invasion of vessels and muscular tissue with extensive necrosis and hemorrhage as shown in [Figure 1]. A report by Nakayama et al. demonstrated the usefulness of a combination of p57kp2 in immunostaining and DNA polymorphism analysis in determining the origin of tubal choriocarcinoma (gestational or nongestational). The histological aspect corroborated with ki-67 index is strongly suggestive of choriocarcinoma in a tubal ectopic pregnancy. The fallopian tube choriocarcinoma can be suspected on MRI when specific fallopian tube-related signs are present, such as solid part showing honeycomb appearance with normal ovaries. Because of the highly metastatic potential of choriocarcinoma, chemotherapy is essential and proves to be very useful. Women treated for extra uterine chemotherapy should receive effective contraception for at least 1 year after completion of their treatment. The monitorization of BHCG is the most useful diagnostic tool in case of tubal choriocarcinoma.
|Figure 1: (a) Laparoscopic image of tubal mass. (b) Histopathologic image of choriocarcinoma in tubal specimen showing atypical cytotrophoblast and synchiotrophoblast with prominent blood vessels|
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| Conclusion|| |
The tubal choriocarcinoma is a rare disease with bad prognosis if not treated. The diagnosis of choriocarcinoma should also be kept in mind while suspecting an ectopic pregnancy with high levels of BHCG. The case signifies the importance of documentation of intrauterine pregnancy and ruling out extrauterine pregnancy with ultrasound before an induced abortion. It also signifies the importance of performing histopathology of tubal specimen in all patients presenting with tubal pregnancy to timely diagnose this extremely rare and highly aggressive but curable malignancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was supported by the Asian Institute of Medical Sciences, Faridabad.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bruce S, Sorosky J. Gestational Trophoblastic Disease. StatPearls: StatPearls Publishing; 2019.
Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet 2010;376:717-29.
Mehrotra S, Singh U, Goel M, Chauhan S. Ectopic tubal choriocarcinoma: A rarity. BMJ Case Rep 2012;2012. pii: bcr-2012-006318.
Karaman E, Çetin O, Kolusari A, Bayram I. Primary tubal choriocarcinoma presented as ruptured ectopic pregnancy. J Clin Diagn Res 2015;9:QD17-8.
Mundkur A, Rai L, Hebbar S, Guruvare S, Adiga P. Fallopian tube choriocarcinoma presenting as ovarian tumour: A case report. J Clin Diagn Res 2015;9:QD01-2.
Rettenmaier MA, Khan HJ, Epstein HD, Nguyen D, Abaid LN, Goldstein BH. Gestational choriocarcinoma in the fallopian tube. J Obstet Gynaecol 2013;33:912-4.
Jia HR, Zhang J, Guo YM. MRI characteristics of primary fallopian tube choriocarcinoma: A case report. Radiol Case Rep 2017;12:300-3.
Sakamoto Y, Takei Y, Fujiwara H, Machida S, Taneichi A, Suzuki M. Gestational choriocarcinoma with uterine serosal metastasis mimicking ruptured ectopic pregnancy: A case report. Oncol Lett 2015;9:2185-8.
Butler R, Chadha Y, Davies J, Singh M. A case of primary tubal gestational choriocarcinoma. Aust N
Z J Obstet Gynaecol 2010;50:200-1.
Berkowitz RS, Goldstein DP. Chorionic tumors. N Engl J Med 1996;335:1740-8.
Muto MG, Lage JM, Berkowitz RS, Goldstein DP, Bernstein MR. Gestational trophoblastic disease of the fallopian tube. J Reprod Med 1991;36:57-60.
Nakayama M, Namba A, Yasuda M, Hara M, Ishihara O, Itakura A. Gestational choriocarcinoma of Fallopian tube diagnosed with a combination of p57KIP2 immunostaining and short tandem repeat analysis: Case report. J Obstet Gynaecol Res 2011;37:1493-6.
Petre IS, Bernad E, Bordianu A, Bernad S. Choriocarcinoma developed in a tubal pregnancy-A case report. Rom J Morphol Embryol 2015;56 Suppl 2:871-4.