Ovarian ectopic pregnancy misdiagnosed as gestational choriocarcinoma: A case report

Choriocarcinoma in tubal pregnancy: A case report

Key Clinical Message

Choriocarcinoma of the fallopian tube is extremely rare and highly susceptible to early metastasis. Clinical manifestations of ectopic pregnancy and choriocarcinoma are the same, and all patients with ectopic pregnancy should be evaluated for choriocarcinoma based on histopathological findings. Adjuvant chemotherapy (after surgery) is the proposed treatment for tubal choriocarcinoma.

Abstract

Choriocarcinoma is a malignant epithelial tumor of the chorionic villi that often manifests after a normal or molar pregnancy. The primary tubal choriocarcinoma associated with ectopic pregnancy is extremely rare and can be misdiagnosed as an ectopic pregnancy since symptoms including vaginal bleeding, amenorrhea, elevated beta-human chorionic gonadotropin (BHCG) levels, and pelvic pain are shared. A 34-year-old G4P3003 woman presented with a one-week history of vaginal bleeding and right lower abdominal pain, which had intensified a day before admission. Clinical and paraclinical examinations pointed to a ruptured tubal pregnancy; hence, an emergency laparotomy was performed, and a right salpingectomy was carried out on the patient. However, a nonsignificant decline in BHCG level was observed, and histological examination revealed tubal choriocarcinoma; hence, a metastasis workup was carried out, yet no metastasis was detected. Six sessions of chemotherapy consisting of Etoposide, Methotrexate, Dactinomycin, Cyclophosphamide, and Vincristine (EMA-CO) were administered without complication, in such a way that the BHCG level normalized after three sessions of chemotherapy. Evaluations after 1 year from the completion of chemotherapy revealed that the patient had no subsequent problems. Choriocarcinoma of the fallopian tube is extremely rare and highly susceptible to early metastasis. Clinical manifestations of ectopic pregnancy and choriocarcinoma are the same, and all patients with ectopic pregnancy should be evaluated for choriocarcinoma based on histopathological findings. Metastasis workup should be considered for all individuals with choriocarcinoma. Adjuvant chemotherapy (after surgery) is the proposed treatment for tubal choriocarcinoma.

Ultra-High-Risk Gestational Choriocarcinoma of the Ovary Associated with Ectopic Pregnancy

Gestational choriocarcinoma of the ovary is an exceptionally rare and highly aggressive tumor. Preoperative diagnosis of extrauterine choriocarcinoma is difficult due to nonspecific clinical presentation and its resemblance to ectopic pregnancy. Without molecular genetic analysis, it is not possible to reliably differentiate gestational from non-gestational choriocarcinoma. Here, we present a case of a 44-year-old woman who presented to our emergency department with complaints of pelvic pain, vaginal bleeding, and amenorrhea. Because of a recent history of conservatively managed ectopic pregnancy, the patient underwent emergency laparoscopy. Right-sided salpingo-oophorectomy was performed due to intraoperatively suspected ovarian ectopic pregnancy. Histopathology results revealed the diagnosis of ovarian choriocarcinoma of possible gestational origin. It was classified as FIGO stage IV and WHO ultra-high-risk, and she underwent multi-agent chemotherapy without major complications. She has remained in complete remission after a 12-month follow-up. Considering the rarity of this diagnosis, we conducted a literature review including all published cases of suspected gestational choriocarcinomas of the ovary. We conclude that due to the rarity of this entity, preoperative differentiating between ovarian ectopic pregnancy and ovarian choriocarcinoma is extremely challenging, and without molecular genetic analysis, it is not possible to identify the genetic origin of the tumor.

Ovarian Pregnancy: 2 Case Reports and a Systematic Review

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum.

Misdiagnosis of intramural ectopic pregnancy and invasive gestational trophoblastic disease on ultrasound: A challenging case at Tu Du Hospital in Vietnam in COVID-19 pandemic peak and mini-review of literature

Differentiation between intramural ectopic pregnancy and molar ectopic pregnancy is very difficult because of their exceptional rarity. Herein, we present a misdiagnosed case of intramural pregnancy and invasive trophoblastic disease on ultrasound. A 45-year-old female patient was admitted to our tertiary referral hospital due to abdominal pain and unusual ultrasonography findings. Initially, a diagnosis of intramural ectopic pregnancy was identified based on transvaginal color Doppler ultrasonography, 3-dimensional ultrasound, and serial serum beta-human chorionic gonadotropin, thus the patient underwent laparotomy with hysterectomy. However, the histopathological endpoint showed an invasive trophoblastic disease. Clinically, this pathology should be included in the differential diagnosis of intramural ectopic pregnancy since an imaging scan remains quite unclear.