Adenocarcinoma of the colon with choriocarcinoma in its metastases

Primary colon adenocarcinoma with choriocarcinoma differentiation: a case report and review of the literature

Background

Choriocarcinoma is an aggressive malignancy of trophoblastic tissue, typically of gestational etiology. Sporadic, nongestational cases are rarely found outside of the gonads. There are only 31 cases of primary choriocarcinoma of the colon reported in the literature. As a consequence of their rarity and aggressive nature, timely diagnosis and effective treatment have proved challenging, and prognosis is very poor. For that reason, we present a rare case with prolonged survival in the youngest reported patient .

Case presentation

A 26-year-old Caucasian woman presented with abdominal cramping and rectal and vaginal bleeding. Elevated serum human chorionic gonadotropin and an 8-cm right-sided mass seen on ultrasound suggested ectopic pregnancy. The patient was treated with methotrexate; however, her symptoms persisted, and her human chorionic gonadotropin levels continued to rise. Further workup showed a large mass of the sigmoid colon with multiple hepatic lesions suggestive of metastases. Preliminary pathology showed adenocarcinoma. Despite surgical resection and initiation of FOLFOX chemotherapy (folinic acid, fluorouracil, oxaliplatin), the patient had significant clinical deterioration, and her human chorionic gonadotropin increased exponentially. Further pathological review showed two distinct phenotypes: adenocarcinoma merging with choriocarcinoma. The result of evaluation of the metastatic lesions was also positive for choriocarcinoma. Treatment was promptly changed to a choriocarcinoma-targeting chemotherapy regimen of EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine), resulting in rapid and dramatic response. The patient had mild progression after 1 year and was switched back to FOLFOX with bevacizumab. After five cycles, scans showed further progression, and the patient was started on third-line therapy with FOLFIRI (folinic acid, fluorouracil, irinotecan) and bevacizumab. Eighteen months after her diagnosis, the patient was alive and maintaining an overall response.

Conclusions

Our patient achieved a marked response and prolonged survival. Although a comprehensive review of the literature showed that survival with these tumors has improved over the past 10 years, prognosis remains poor. Currently, there is no established algorithm for the management of these rare tumors, but both the literature and our patient’s case indicate that a choriocarcinoma-targeted regimen is critical for survival. Further evaluation of these rare tumors is warranted in order to identify pathological patterns that may help in the diagnosis, management, and survival of these malignancies.

Unusual abscess masquerading as poorly differentiated adenocarcinoma of the colon showing characteristics of choriocarcinoma

Extragonadal non-gestational choriocarcinoma (ENC) is an uncommon malignant tumor occasionally found in the gastrointestinal tract. ENC is characterized by a biphasic tumor growth with distinct areas of adenocarcinoma and choriocarcinoma differentiation. Primary choriocarcinoma of the colon is extremely rare, with only 21 cases reported in the literature. Most of the perforation of colorectal cancers occurs in the abdominal cavity, while abdominal wall abscess is rare; the psoas abscess associated with colon carcinoma is even less observed. Herein, we report the case of a 61-year-old female with poorly differentiated adenocarcinoma of the ascending colon and sigmoid, with choriocarcinomatous differentiation, masquerading a psoas abscess formation. Unfortunately, despite the aggressive therapy, the patient’s disease rapidly progressed, and she died within 2 months after the diagnosis. The typical morphological pattern, immunohistochemistry, and its correlation with serum β-human chorionic gonadotropin enabled a correct diagnosis.

A rare case of primary rectal choriocarcinoma and review of the literature

INTRODUCTION

Primary choriocarcinoma of the colon is an extremely rare neoplasm which has a poor prognosis. Only 18 cases have been previously reported in English medical literature. Here we present a case of primary rectal choriocarcinoma with a good response to chemotherapy and review the literature on this uncommon tumor.

CASE REPORT

A 36-year-old woman presented with abdominal pain and vaginal bleeding. Abdominal magnetic resonance imaging revealed 6.9 × 5.3 × 6.4 cm hypervascular mass posterior to uterus very close to rectum. Beta-human chorionic gonadotropin (β-hCG) level was markedly elevated. Low anterior resection of the rectum with lymph node dissection and total abdominal hysterectomy with bilateral salpingo-oophorectomy were performed. Pathologic diagnosis was reported as colonic choriocarcinoma with a focal component of adenocarcinoma. Post-operative magnetic resonance imaging detected multiple metastatic lesions throughout the liver. The patient was treated with systemic chemotherapy using bleomycin, etoposide and cisplatin (BEP protocol). After three cycles, β-hCG level decreased to normal and magnetic resonance imaging showed regression of liver metastasis. However, the patient died of respiratory failure due to bleomycin toxicity and pneumonia accompanied by rapid disease progression.

DISCUSSION

This is an extremely rare case of primary rectal choriocarcinoma. Due to poor prognosis of the disease, it seems very important to start prompt treatment to improve patient's survival.

Primary Adenocarcinoma with Focal Choriocarcinomatous Differentiation in the Sigmoid Colon

Primary colorectal choriocarcinoma is a rare neoplasm. Only 19 cases have been reported worldwide, most of which involved adenocarcinomas. The prognosis is usually poor, and the standard therapy for this tumor has not been established. A 61-year-old woman presented with constipation and lower abdominal discomfort. She was diagnosed with primary adenocarcinoma with focal choriocarcinomatous differentiation in the sigmoid colon and liver metastasis. Because the serum beta-human chorionic gonadotropin level was not significantly elevated, and because only focal choriocarcinomatous differentiation was diagnosed, we selected the chemotherapy regimen that is used for the treatment of metastatic colorectal adenocarcinoma. The patient survived for 13 months after the initial diagnosis. This is the first case in Korea to assess the suppressive effects of the standard chemotherapy for colorectal adenocarcinoma against coexisting colorectal choriocarcinoma and adenocarcinoma.

Primary Choriocarcinoma of the Rectum in a Man Case Report and Literature Review

A case of pure extragonadal choriocarcinoma in the rectum of an 84-year-old man is described. The patient complained of rectal bleeding and lower abdominal pain. The trophoblastic origin of the tumor was documented by immunoperoxidase staining for human chorionic gonadotropin. The DNA histogram showed a diploid pattern. The patient died 106 days after diagnosis. Only eight cases of choriocarcinoma of the large intestine have been reported, three of which were located in the rectum. The age of patients affected range widely, from 28 to 84 years with a mean of 54 years: 79 for males and 46 for females. Women are affected three times as often as men. The pathologic study showed adenocarcinoma with germ cell elements in seven cases: six choriocarcinoma and one mixed (choriocarcinoma and endodermal sinus tumor). Germ cell differentiation may be difficult to identify in small biopsy samples, which may not be representative of the tumor as a whole. The prognosis of patients with choriocarcinoma of the large bowel is very poor; survival is less than 5 months. Although choriocarcinoma in the rectum is very rare, it should be included in the differential diagnosis of rectal neoplasms.

Primary choriocarcinoma of the colon: a case report and review of the literature

Choriocarcinoma usually arises in the uterus and gonads. Primary choriocarcinoma (PCC) in an extragenital organ is rare. When it occurs in the gastrointestinal tract, the stomach is the most common site. Only 12 cases of PCC of the colon have been reported in the world literature. Most cases were associated with adenocarcinoma. We report the case of a 36-year-old man with PCC of the colon and review the clinical characteristics of previously documented cases.

Choriocarcinoma of the sigmoid colon: report of a case

We report a rare case of primary choriocarcinoma of the colon. A 58-year-old woman underwent Hartmann's procedure to remove a sigmoid colon tumor, and pathological examination confirmed choriocarcinoma that had originated from the colon. Radical surgery combined with chemotherapy gives the best chance of long-term survival.

Gallbladder adenocarcinoma with human chorionic gonadotropin: a case report and review of literature

Background

The case of adenocarcinoma with human chorionic gonadtropin (HCG), primary in the male gallbladder, is extremely rare. A Medline search has shown only a few similar cases reported.

Methods

We herein describe a case of primary gallbladder adenocarcinoma associated by ectopic HCG positive tumor cells in a 79-year-old male.

Results

Pathological examination showed a mixture of moderately and poorly differentiated adenocarcinoma with ectopic HCG and placental alkaline phosphatase (PlAP) in tumor cells, though the increase of serum or urinary HCG secretion was not confirmed. The literatures were also reviewed.

Conclusions

A case of gallbladder cancer with ectopic HCG production is quite rare in the literature, though many similar cases in other site, especially in GI tract, are reported. Embryological consideration suggests the increased frequency of similar cases more than being thought now.

Expression of embryonic characters by malignant cells

While the expression of fetal characters by malignant cells is now well-documented, the mechanism involved and the nature of the cells that are the target of malignant transformation remain controversial. It has often been assumed that carcinogenesis results in 'dedifferentiation' of specialized cells. The alternative hypothesis is that neoplasia results from a disorder of some normal stem cells. This view is discussed in relation to several examples, in particular teratocarcinomas.

Serous carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature indicate the existence of 2 prognostically relevant tumor types

Nongestational choriocarcinomas rarely occur outside the gonads or teratomas. We report a serous carcinoma of the endometrium with a choriocarcinomatous component and review of the literature. A 61-year-old woman underwent hysterectomy and bilateral salpingo-oophorectomy for a serous carcinoma with choriocarcinomatous component. Immunohistochemistry showed a strong p53 staining of the serous component and the cytotrophoblastic cells of the choriocarcinomatous component; the syncytiotrophoblast was negative. The initial serum human chorionic gonadotropin (hCG) was 225,000 IU/L. Postoperatively, the patient developed diffuse pulmonary metastatic disease. Despite chemotherapy, the patient died 2 months after initial diagnosis. Abstracting the data from the reported cases and from the literature, it can be assumed that 2 different tumor types exist. The first one is morphologically and clinically more related to the gestational choriocarcinoma with strongly elevated serum hCG levels, early onset of (distant) metastatic disease, and consecutively rapid and often fatal clinical course. The second type presents as an endometrial carcinoma with single syncytiotrophoblast-like cells, associated with low serum hCG, no distant metastatic disease, and, consequently, a better prognosis. The prognostically relevant component for long-time survival in the latter variant is the nontrophoblastic component.

Fine-needle aspiration biopsy of a case of breast carcinoma with choriocarcinomatous features

Breast disease is of great concern to patients and health care providers alike. Malignancies of the breast and their various presentations can pose tremendous challenges with respect to early diagnosis and effective treatment. Carcinoma of the breast may appear in several forms and produce one or more ectopic substances. Breast carcinomas that display choriocarcinomatous differentiation and produce human chorionic gonadotropin are very rare. Less than a dozen such cases have been described in the medical literature to date. We report a case of breast carcinoma with choriocarcinomatous features, which is the first to show immunohistochemical evidence of the expression of both estrogen receptor and progesterone receptor. We also discuss the cytopathologic aspects observed and conduct a literature review.

Rectal adenocarcinoma with choriocarcinomatous differentiation: Clinical and genetic aspects

Nongestational choriocarcinomas are rare tumors. In the gastrointestinal tract, they are characterized by a biphasic tumor growth with separated areas of adenocarcinomatous and choriocarcinomatous differentiation. We here report a case of a combined adenocarcinoma-choriocarcinoma of the rectum. The tumor showed an aggressive clinical behavior with metastasis to the liver and lungs. A transient partial remission was achieved after 4 cycles of cisplatinum, etoposide, and ifosfamide chemotherapy, with normalization of serum beta-human chorionic gonadotropin levels. At this time, viable residual choriocarcinoma cells were found in surgically resected lung metastasis. The patient succumbed 8 months after initial diagnosis to a rapid abdominal relapse. We used comparative genomic hybridization (CGH) and fluorescence in situ hybridization to elucidate the genetic relationship of adenocarcinoma and choriocarcinoma in this neoplasm. We found genetic changes characteristic for colorectal adenocarcinomas, a loss of chromosomal regions 8p21-pter as well as 18q21-pter, and a gain of 5p and 20q, in both tumor parts. This provides evidence for the common origin of both components. A differential pattern of additional genetic changes suggests a clonal evolution from a common ancestor cell. In contrast to findings from a comparative study on a choriocarcinoma of the renal pelvis, we did not find an amplification of the germ cell cancer-associated chromosomal region 12p11.2-p12.1 in the areas of choriocarcinoma but found instead a loss of Xp11.3-pter. To our knowledge, this is the first report of a CGH comparison of the adenocarcinomatous and choriocarcinomatous tumor parts in a nongestational choriocarcinoma of the gastrointestinal tract.

Rectal adenocarcinoma with germ-cell differentiation: report of a case

A 26-year-old male presented with a colorectal adenocarcinoma with germ-cell differentiation and an isolated elevation of serum alpha-fetoprotein. He was treated with platinum/etoposide/bleomycin chemotherapy with a decrease in serum alpha-fetoprotein and in the size of the primary tumor. An ongoing tumor-marker response occurred when the patient was switched to concurrent 5-fluorouracil chemotherapy and radiation therapy. The patient underwent a palliative diversion of his rectal cancer 10 months after diagnosis, developed liver metastasis at 12 months, and died 20 months after diagnosis.

Breast carcinomas with choriocarcinomatous features: case reports and review of the literature

Breast cancer with choriocarcinomatous features is rare. This report describes four cases of breast cancer with choriocarcinomatous features. The tumor cells were positive for human placental lactogen (hPL) and human chorionic gonadotropin (hCG) by immunohistochemistry. The cases reported in the literature had a poor prognosis and the patients died within a few months after the diagnosis. In this series, two cases were lost to follow-up, but the other two have had disease-free survival for 2 and 4 years, respectively.

Choriocarcinomatous metaplasia of a metachronous adenocarcinoma of the colon

A second primary colonic adenocarcinoma developed in a 68-year-old man following resection of a rectal adenocarcinoma. Choriocarcinomatous change was found in the metachronous lesion with liver metastases and elevated beta-human choriogonadotrophin (HCG) serum titres.

Colonic adenocarcinoma metastasizing as a germ cell neoplasm: a case report and review of the literature

Mixed tumors of the gastrointestinal tract, including both adenocarcinoma and germ cell neoplasm, have been reported infrequently. In the colon, only 9 cases, to our knowledge, have been described in the English-language literature. This is the case of a 29-year-old man with an unsuspected mixed colonic neoplasm that metastasized as the germ cell component.

Tissue expression of human chorionic gonadotropin beta predicts outcome in colorectal cancer: a comparison with serum expression

Production of the glycoprotein hormone human chorionic gonadotropin beta (hCGbeta) has been associated with more aggressive behavior in non-trophoblastic tumors. In this study, the prognostic value of immunohistochemical hCGbeta expression was evaluated in 239 patients with colorectal cancer. Paraffin-embedded, formalin-fixed specimens were stained with hCGbeta-specific monoclonal antibody, and the results were compared with serum levels determined with an assay based on the same antibody. hCGbeta immunoreactivity was seen in 52 of 239 tumors (22%). The difference in survival time between patients with histologically hCGbeta-negative (median survival 94 months) and -positive (median survival 27 months) tumors was statistically significant (p = 0.014). The risk ratio during follow-up for patients with positive hCGbeta tissue expression was 1.65 (95% CI 1.11-2.46). In a Cox multivariate analysis, Dukes' stage, hCGbeta and age remained independent prognostic factors. There was moderate agreement between immunohistochemical and serum expression levels of hCGbeta (kappa = 0.30). Using a combination of histological and serum levels of hCGbeta, the difference between survival rates was highly significant (p < 0.001). The accuracy when predicting 5-year survival status with the combined results of serum and tissue expression was 1.3% higher compared to hCGbeta tissue expression alone. Our results show that hCGbeta expression in both tumor tissue and serum has prognostic significance independent of other clinicopathological variables. Positive tumor staining does not always occur together with elevated serum levels, and the prognostic accuracy can slightly be increased by combining the results.

Choriocarcinome pur du testicule : à propos d'un cas avec revue de la littérature

We report a case of a young man 31 years old treated at the Ibn Rochd Oncology Center for a pure choriocarcinoma of the right testis. The first examination note a skin metastasis without another localization. The beta HCG level was 328 mu/mL. The diagnosis was confirmed by pathological examination of the testis after orchidectomy. The adjuvant treatment consisted in chemotherapy like using in germ cell neoplasm's of the testis. During the evolution, partial remission (50%) was obtained after the third course and complete remission one month after the end of treatment. The patient still alive after 20 months.

Endometrial adenocarcinoma with trophoblastic differentiation

OBJECTIVE

To report a case of stage IIIc poorly differentiated endometrial adenocarcinoma with trophoblastic differentiation and to review previously reported cases.

METHODS

The clinical course and histopathology of the case were reviewed, and a literature search for other reported cases was performed.

RESULTS

The tumor contained syncytiotrophoblast-like giant cells that stained positively for the beta subunit of human chorionic gonadotropin (beta-hCG), and the patient's serum beta-hCG level was elevated (95 mIU/ml), but became undetectable after treatment. Beta-hCG was used as a tumor marker during further therapy. At 16 months' survival, she remains without evidence of disease and with a beta-hCG (level < 5 mIU/ml). Nine other cases of trophoblastic differentiation in gynecologic nontrophoblastic tumors have been reported, five in endometrial carcinomas which we review.

CONCLUSIONS

Trophoblastic differentiation in gynecologic nontrophoblastic tumors is rare. Beta-hCG may be useful as a tumor marker in these cases. The clinical behavior of these tumors has been aggressive, with advanced stages at diagnosis, early widespread metastases or recurrences and poor patient outcomes. The patient presented in this report, however, remains without evidence of disease 16 months following diagnosis and may be the longest survivor with this tumor reported to date.

Metastatic testicular choriocarcinoma of the skin. Report and review of the literature

Choriocarcinoma is a malignant growth of trophoblastic cells characterized by secretion of human chorionic gonadotropin. Choriocarcinoma usually arises from fetal trophoblasts and rarely arises from germ cells in the testis or ovary or derives from dedifferentiation of other carcinomas. Skin metastasis of choriocarcinoma is rare: only seven cases have been reported in the English and Japanese literature. We report the case of a 22-year-old Japanese man with pure choriocarcinoma of the testis who developed skin metastases that presented as multiple reddish nodules. Microscopic examination of both the primary lesion of the testis and the cutaneous metastasis demonstrated the typical histologic features of pure choriocarcinoma. The patient died 3 months after the initial onset of skin metastasis. Review of the literature indicates that skin metastasis of choriocarcinoma usually occurs as a nodular lesion with the histologically typical feature of the primary disease and signals of poor prognosis.

Uterine cervical clear-cell adenocarcinoma with a choriocarcinomatous component: a case report

A 55-year-old woman presented with vaginal bleeding. A tumor was found in the cervix; it was composed of 2 distinctive elements: a clear-cell adenocarcinoma and a choriocarcinoma. Histologic findings suggested that the choriocarcinomatous element was derived from a preexisting clear-cell adenocarcinoma through a metaplastic process.

Coexistence of choriocarcinoma and adenocarcinoma in the rectum: molecular aspects

Choriocarcinoma, a malignant tumor of usually placental origin, in divided into two groups; the gestational and non-gestational types, the latter being rare. Non-gestational choriocarcinoma occurs in the lung, mediastinum, kidney, stomach, and small intestine, but rarely appears in the large intestine. We treated a 29-year-old woman with choriocarcinoma of the rectum with adenocarcinoma. Despite the rarity of the condition and the obscurity of the histogenesis, reports of similar cases and the occurrence of the tumors in the digestive tract suggest that the condition constitutes a clinical entity of a digestive tumor.

Rectal adenocarcinoma with germ cell elements treated with chemotherapy

A patient with adenocarcinoma of the rectum containing germ cell elements in the form of endodermal sinus tumor and choriocarcinoma is described, believed to be the first such tumor reported in the literature. The serum levels of alpha-fetoprotein and human chorionic gonadotropin were markedly elevated. The source of the markers was localized to the neoplastic tissue by the immunoperoxidase technique. The patient developed extensive hepatic metastases thought to be due to choriocarcinoma for which she received chemotherapy. One wk after commencing treatment a massive fatal hepatic hemorrhage occurred.

Primary pure choriocarcinoma of the liver

We report a pure choriocarcinoma of the liver studied at necropsy. The tumour was diagnosed ante-mortem and treated by chemotherapy with no satisfactory response. Previous cases of hepatic choriocarcinoma are reviewed and criteria to diagnose this extragonadal neoplasm are recommended.

Cell lineage markers in premalignant and malignant colonic mucosa

Normal colonic epithelial cells consist of several cell types or lineages that are thought to arise from a common stem cell precursor. Neoplastic transformation may occur at different stages in the differentiation of a colonic stem cell to produce tumors that may retain characteristic cell lineage phenotypes. In this study, immunohistochemical techniques were used to identify cell lineage-related markers in fetal, normal, hyperplastic, adenomatous, and cancerous colonic tissue. These markers consisted of secretory component (columnar cells), a purified mucin antigen (mucous or goblet cells), chromogranin A (enteroendocrine cells), lysozyme (Paneth cells), and carcinoembryonic antigen (panepithelial cell marker). Colonic neoplasms, like normal mucosa, predominantly expressed the markers of columnar and goblet cell lineages. Chromogranin A was expressed in a small population of cells in most normal and fetal colonic crypts. Chromogranin A reactive cells were found in 55% of hyperplastic polyps, 31% of adenomatous polyps, and 33% of carcinomas. Lysozyme reactivity was rare in fetal, normal, and hyperplastic specimens, but was present in 86% of adenomas and 40% of carcinomas. Of 42 primary carcinomas, 9% were "pluripotent" and expressed markers of all four cell lineages. In addition to columnar and goblet cell markers, 7% expressed both enteroendocrine and Paneth cell markers, 17% expressed enteroendocrine cell markers, and 24% expressed Paneth cell markers. Two cases (5%) lacked expression of any of the cell lineage markers. The remainder expressed only columnar and goblet cell markers. The markers used in this study appear to identify the major cell lineages of fetal and normal colonic epithelium and can be used to delineate the altered cell lineage phenotypes in premalignant and malignant colonic mucosa.

Placental proteins in high-grade urothelial neoplasms. An immunohistochemical study of human chorionic gonadotropin, human placental lactogen, and pregnancy-specific beta-1-glycoprotein

We examined the presence of human chorionic gonadotropin (HCG) in 16 low-grade and 47 high-grade urothelial neoplasms, including two cases with trophoblastic-like differentiation. In HCG-positive tumors, the presence of human placental lactogen (HPL) and pregnancy-specific beta-1-glycoprotein (SP-1) also was assessed. HCG immunoreactive cells were found in nine of the 47 high-grade tumors (19%), whereas none of the low-grade tumors were positive for HCG. This hormone was predominantly detected in the most undifferentiated and pleomorphic areas; however, HCG-positive cells also were found in areas of carcinoma in situ and well-differentiated transitional cell carcinoma in two cases. The serum HCG level was increased in two of the four cases studied. HPL and SP-1 immunoreactive cells were observed in seven and five cases, respectively, and it was found that tumors positive for SP-1 also were positive for HPL. Five tumors, including the two with trophoblastic differentiation, contained the three placental proteins. The HPL and SP-1 immunostained cells were usually found in the same areas of the tumor that were positive for HCG, but there was always a lower number of HPL and SP-1 immunoreactive cells than HCG immunoreactive cells. In one case, HPL and SP-1 could be found in areas of well-differentiated transitional cell carcinoma. These findings suggest that the morphologic and functional trophoblastic differentiation in urothelial carcinomas is a progressive phenomenon evolving from transitional cell carcinomas.

Primary choriocarcinoma of the lung: report of a case treated with intensive multimodality therapy and review of the literature

Primary choriocarcinomas of the lung are extremely rare. Like choriocarcinomas elsewhere, they possess rapid growth ability and a high propensity to metastasize. There is minimal information available on the treatment of lung choriocarcinoma. In the case reported herein, neoadjuvant chemotherapy with 5-fluorouracil (5-FU) infusion, etoposide, and cisplatin induced a partial response permitting complete excision of a massive tumor of the right upper lobe involving the chest wall and superior vena cava. The patient relapsed with a metastasis to the brain that was surgically excised. Contralateral lung metastases were soon noted and responded well to systemic chemotherapy; yet the patient died of a new brain metastasis. To our knowledge, this is the first example of a primary choriocarcinoma of the lung treated with intensive multimodality therapy. The latter seems to offer a potential benefit if certain guidelines are followed.

Adenocarcinoma of the uterine cervix with beta-hCG production: a case report and review of the literature

The production of unexpected cell products, including the placental protein human chorionic gonadotrophin (hCG), has been reported in a variety of tumors at different anatomical sites. Some of the reported tumors have also expressed morphological features suggesting choriocarcinoma. Such is the case in this tumor of the uterine cervix which has a major component of anaplastic tumour with beta-hCG production confirmed both by positive staining using immunoperoxidase techniques and by pre- and postoperative serum assays for beta-hCG. The differing immunohistochemical features seen in the two components of the tumor are reported. The relationship of the anaplastic component to the adjacent mucinous adenocarcinoma in the present case, and to similar cases at other sites from the literature, is discussed.

Ovarian yolk sac tumor arising from an endometrioid carcinoma

A yolk sac tumor that arose within an ovarian endometrioid adenocarcinoma in a 50-year-old woman is described. The tumor had typical microscopic features, stained immunohistochemically for alpha-fetoprotein, and was associated with an elevated serum alpha-fetoprotein level when metastases appeared. This is the fourth case in which a yolk sac tumor has been reported to develop from a somatic carcinoma and the second in which this tumor has been associated with epithelium of endometrioid type. Tumor heterogeneity or neometaplasia may account for the origin of a tumor of germ cell type from a carcinoma of somatic origin.

Adenocarcinoma of the endometrium with trophoblastic differentiation and metastases as choriocarcinoma: a case report

Nongestational choriocarcinoma is seldom observed outside of gonads or teratomas. No case of choriocarcinoma arising in endometrium is reported in the literature. Here we present a 70-year-old female with endometrial adenocarcinoma focally differentiating to choriocarcinoma, and metastasizing to liver, kidney, brain, and lung as pure choriocarcinoma. Foci of trophoblastic differentiation in the primary endometrial lesion and metastatic lesions are positive for hCG by immunocytochemical stain. This case is similar to gastrointestinal and lung carcinomas that contain trophoblastic change. Possible histogenesis of this tumor is discussed.

Human chorionic gonadotrophin expression in colorectal adenocarcinoma

The presence of human chorionic gonadotrophin (HCG) in colorectal adenocarcinoma was studied histologically in 45 tumors using immunoperoxidase technique. Ten neoplasms (22.2 percent) contained HCG-positive tumor cells. These cells were present mostly at the periphery of the tumors. Many formed parts of glands, while some were arranged in syncytial clumps or columns, or singularly. Thus, these tumor cells resembled trophoblastic tissue not only in being HCG-positive but also in their peripheral distribution and occasionally in morphologic appearance. HCG-positive tumors were seen more commonly in the rectosigmoid region (90 percent) and were more aggressive than HCG-negative tumors. In this study, lymph node or liver metastases were present in 70 percent of HCG-positive tumors compared with 29 percent of negative tumors--a difference which is statistically significant.

Gastric choriocarcinoma; an immunohistochemical study

A case is reported of primary gastric choriocarcinoma occurring in a 73-year-old man, associated with a high serum level of beta hCG. Both primary and lymph node metastases contained exclusively cyto and syncytiotrophoblastic elements. Immunohistochemical localization of chorionic gonadotropin (hCG), placental lactogen (hPL) and pregnancy-specific glycoprotein (SP 1) is described in relation to cytotrophoblastic differentiation. An intramucosal focus of adenocarcinoma supports the hypothesis of the origin of choriocarcinoma from usual gastric cancer.

Human chorionic gonadotropin production by colon carcinoma. Biochemical heterogeneity and identification of a chemotherapy-sensitive cell subpopulation

Human chorionic gonadotropin (hCG) is produced and secreted by a wide variety of human neoplasms and represents one example of biochemical heterogeneity in tumors. The authors report two patients with advanced hCG-producing colon carcinomas in whom immunohistochemical staining demonstrated a distinct hCG-producing cell subpopulation. Both patients had objective tumor responses when treated with chemotherapy effective against germinal neoplasms. Responses were characterized by prompt and substantial reduction in plasma hCG levels and by improvement in clinical status, radiographic tumor measurements, and other biochemical abnormalities. These epithelial carcinomas responded to chemotherapeutic agents that are usually ineffective, and striking chemosensitivity was observed in the hCG-producing cell subpopulation. These two cases provide initial evidence that hCG-producing cells are sensitive to certain chemotherapeutic agents even when they are a part of common epithelial somatic tumors, and that this sensitivity represents another type of heterogeneity in human tumors. The identification of hCG production in epithelial tumors may be important in determining therapeutic strategy.

Pancreatic choriocarcinoma presenting as inflammatory pseudocyst

A primary pancreatic choriocarcinoma was discovered at surgery in a patient with a clinical diagnosis of pancreatic inflammatory pseudocyst. To our knowledge, this is the first example of an extragonadal choriocarcinoma reported as a primary at this site. We consider this neoplasm to be another example of a visceral choriocarcinoma arising from a primary carcinoma through a process of metaplasia. This case illustrates the inherent difficulties in the preoperative evaluation of cystic lesions of the pancreas, and the importance of recognizing endocrinologic manifestations of malignant disease.

Adenocarcinoma of the colon with syncytiotrophoblastic differentiation: differential diagnosis and implications

A case of adenocarcinoma of the colon is reported, whose metastases exhibited a syncytiotrophoblastic differentiation that gradually increased with advancing distance from the primary. Immunohistochemically, syncytiotrophoblastic giant cells with strong positivity for beta-HCG could be demonstrated within the metastatic tissue. Also, there was beta-HCG positivity in a fraction of the atypical epithelial elements of the primary. The case is discussed with respect to the differential diagnosis, and the cause of the syncytiotrophoblastic differentiation is attributed to the phenomenon of genetic instability. The case shows that by virtue of genetic instability totally new differentiations may be elaborated, so that the phenotypical appearance of a given tumor does not necessarily allow conclusions as to its tissue of origin. Thus, observations such as the one presented here clearly indicate that the histogenetic principle of tumor classifications by far does not apply to all cancers and that, therefore, its value and validity are considerably limited.

Coexistence of adenocarcinoma and choriocarcinoma in the sigmoid colon

A rare case of a colon carcinoma that developed in a 50-year-old woman is documented. Histologically, the removed tumor was composed of two distinctive elements, i.e., well-differentiated papillary adenocarcinoma and choriocarcinoma. It was strongly suggested that the latter malignancy derived from the pre-existing colonic carcinoma through metaplastic proliferation. A very high human chorionic gonadotropin level was noted in the patient's serum obtained at the preoperative stage. Autopsy materials revealed that metastatic foci in the liver, lungs, and lymph nodes were exclusively composed of choriocarcinoma.

The probable origin of an anemone cell tumor: metastatic transitional cell carcinoma producing HCG

A neoplasm of unknown origin in cervical and axillary lymph nodes was diagnosed as anemone cell tumor by ultrastructural examination. Three years after the initial diagnosis of anemone cell tumor, a high-grade transitional cell carcinoma of the bladder was discovered. The results of immunoperoxidase staining of the cervical lymph node, axillary lymph node, and bladder tumors for keratin, carcinoembryonic antigen, and human chorionic gonadotropin (HCG) strongly suggest that the anemone cell tumors in this case represent metastases of bladder carcinoma cells capable of producing HCG.

Undifferentiated carcinoma of the colon containing exocrine, neuroendocrine and squamous cells

The light microscopic, electron microscopic and histochemical features of a highly malignant colonic tumor resected from a 39 year old man are presented. The tumor was composed predominantly of undifferentiated cells with focally admixed neuroendocrine, exocrine and squamous cells, occasionally arranged in an organoid manner. Histochemically the tumor contained argyrophilic cells as well as cells that reacted positively with the antibodies to alpha-1-antitrypsin, alpha-1-antichymotrypsin, carcinoembryonic antigen and lysozyme. The term "stem cell carcinoma of the intestine" is proposed for this highly malignant tumor composed of undifferentiated cells exhibiting only focally their multidirectional developmental capacity.

Effects of antibodies to choriogonadotropin in malignant growth. I. Rat 3230 AC mammary adenocarcinoma

To determine whether the in vivo production of antibodies against choriogonadotropin (CG) could modify the relationship between host and malignant growth, the effects of preimmunization with a conjugate of the beta-subunit of CG and tetanus toxoid (CG beta-tt) on the development and growth of lung metastasis following I.V. injection of R 3230 rat mammary adenocarcinoma cells into Fischer 344 female rats have been investigated. This neoplasm has been previously demonstrated to synthesize CG-like material. A test group of 70 animals and two matched control groups of 15 animals each were used. One of the control groups was untreated and the other received tetanus toxoid only. All the control animals had multiple lung foci of neoplastic cells ten days after seeding, as has been previously observed, and CG antibodies were undetectable. In contrast, a significant titer of anti-CG was found in all preimmunized animals. At the same time, the pretreated animals rarely had a few small neoplastic nodes in the entire lung sections at the standard 8--10 days post-seeding. The protective effects of preimmunization with CG beta-tt were further demonstrated by the animals living 20 days post-seeding, the absence of lung pathology in the ones killed thereafter, and by six animals that were left alive and have not shown any deterioration for more than six months after the administration of the cell suspension.

Ductuloinsular tumors of the pancreas: a light, electron microscopic and immunohistochemical study

Most pancreatic tumors are of a single cell type and are identified delta as duct, acinar, or islet cell neoplasms. The authors report on three examples with both duct and endocrine characteristics as seen by light microscopy; two with further confirmation of endocrine differentiation by electron microscopy; and one by immunocytochemistry. Mixed differentiation of this sort can be understood by reference to the embryonic pancreas, which develops from the small intestine and forms ducts, intercalated ducts, acini, and islets, with their different cell types. The merging and intermingling of different cell prevents the identification of one specific cell of origin. It also suggests that the neoplastic process here may not be a clonal proliferation from a single cell mutation as this is generally understood. Alternative explanations are briefly mentioned.