Successful surgical treatment of recurrent choriocarcinoma with laparoscopic resection of intraperitoneal pelvic tumor

Kuan-Gen Huang, Nor Anita Abdullah, Aizura-Syafinaz Adlan, Shir-Hwa Ueng, Tsung-Ying Ho, Chyi-Long Lee
2013 Taiwanese Journal of Obstetrics & Gynecology  
Choriocarcinoma is a rare malignant spectrum of gestational trophoblastic disease (GTD) and may arise after miscarriage, molar pregnancy, or term delivery. The incidence of choriocarcinoma after miscarriage or term delivery is estimated to be 1 in 50,000 pregnancies [1] . The ultrasound findings for choriocarcinoma can be normal, with an elevated beta-human chorionic gonadotrophin (b-hCG) level. Persistent disease is responsive to chemotherapy in more than 90% of cases; based on World Health
more » ... anization (WHO) risk scoring criteria, either single-agent or multiagent chemotherapy will be used [2] . However, 25% of those with a high-risk WHO score and 5% with a low-risk WHO score have an incomplete response to chemotherapy or experience relapse following a period of remission [3]. Among these selected patients, surgical resection of localized disease may be considered as an alternative approach. In this paper, we present a case of focal recurrent choriocarcinoma successfully treated with laparoscopic surgical resection without adjuvant chemotherapy. A 32-year-old woman who had four previous pregnancies presented to the emergency department during her early gestational weeks with lower abdominal pain and a positive urine pregnancy test. Physical examination revealed tenderness at the lower quadrant. Pelvic ultrasonographic examination showed a hyperechoic endometrial lining without evidence of intrauterine pregnancy. A right solid hyperechoic adnexal mass measuring 4 cm 3 cm was seen outside the uterine cavity, along with fluid at the cul-de-sac. No fetal activity was detected and findings were consistent with an ectopic pregnancy. The b-hCG level was elevated at 7400 m IU/L. The patient underwent emergency laparoscopic right salphingectomy and endometrial curettage. The intraoperative finding was right tubal gestational tissue with hemoperitoneum of 800 mL. The histology of endometrial curettage and adnexa mass were complete hydatidiform mole of the uterus and hemorrhagic trophoblastic cell of the right fallopian tube, respectively. Postoperative follow-up revealed persistently elevated levels of b-hCG (17,094 m IU/L). A diagnosis of GTD was made. According to WHO scoring criteria, the patient was in the low-risk group and received six cycles of single-agent methotrexate (50 mg/m 2 ). Despite administration of single-agent chemotherapy, the patient's b-hCG levels remained high; therefore, a second-line multiagent chemotherapy regimen, EMACO (etoposide 100 mg/m 2 , methotrexate 300 mg/m 2 , actinomycin 0.5 mg, cyclophosphamide, and vincristine 1 mg/m 2 ), was started. Her b-hCG levels returned to a normal level after completion of the second-line chemotherapy. The patient remained in remission for 7 months. However, after the period of remission, an incremental increase of b-hCG level was noted. The patient was counseled regarding the need for multiagent chemotherapy but she refused this treatment. Computed tomography (CT) and transvaginal ultrasonography were normal, fludeoxyglucosepositron emission tomography (FDG-PET) scan showed a focal F18 FDG uptake lesion in the right lower pelvic area with maximum standardized uptake value of 4.7 (Fig. 1) . CT
doi:10.1016/j.tjog.2013.04.027 pmid:23915869 fatcat:2ow3gvkiljemphh2qsesredoii