Autopsy case of primary choriocarcinoma of the urinary bladder

Urothelial Carcinomas With Trophoblastic Differentiation, Including Choriocarcinoma: Clinicopathologic Series of 16 Cases

Trophoblastic differentiation (including choriocarcinoma) arising in urothelial carcinoma has been described in numerous case reports, but never in a single series. We present a series of these tumors, describing the morphologic spectrum, applying traditional and novel immunohistochemical stains, and characterizing clinical follow-up. We identified 16 cases, arising predominantly in the bladder (N=14), but also the ureter (N=1) and prostatic urethra (N=1). Six of our cases (38%) contained invasive urothelial carcinoma with admixed syncytiotrophoblasts, 8 cases (50%) consisted of invasive urothelial carcinoma with choriocarcinoma, 1 case (6%) showed urothelial carcinoma in situ with associated choriocarcinoma, and 1 case (6%) consisted of pure choriocarcinoma. Other subtypes of variant morphology were seen in 5 of our cases (31%) and included squamous, glandular, lipoid, chordoid/myxoid, and sarcomatoid features. Given the limited specificity of human chorionic gonadotropin immunohistochemistry, we also studied the expression of a novel specific trophoblastic marker, hydroxyl-δ-5-steroid dehydrogenase, as well as Sal-like protein 4. Human chorionic gonadotropin expression was seen in nearly all cases (93%) but was often not limited to the trophoblastic component, staining the urothelial component also in 85% of the cases. Expression of hydroxyl-δ-5-steroid dehydrogenase was more sensitive and more specific, staining 100% of the cases and limited to trophoblasts in all but 1 case. Sal-like protein 4 expression was variable, staining trophoblast in only 50% of cases and staining the urothelial carcinoma component in 43% of those positive cases. Most of our tumors presented at a high stage and were associated with poor clinical outcomes, with at least muscle-invasive disease (pT2) in 10 of the 14 bladder tumors (71%), periureteric fat invasion in the ureter tumor (pT3), distant metastases in 7 of 16 cases (44%) and death of disease in 3 of the 15 patients with follow-up (20%). Our study describes a series of urothelial carcinomas with trophoblastic differentiation, demonstrating the morphologic spectrum of this entity, its frequent association with other subtypes of variant morphology, its characteristic immunoprofile, and its aggressive clinical behavior.

GATA-3 expression in primary pure choriocarcinoma of the bladder

INTRODUCTION

Primary pure choriocarcinoma of the bladder is extremely rare and should be distinguished from urothelial carcinoma. GATA-3 is a zinc finger transcription factor and a known sensitive immunostaining marker for urothelial carcinoma. However, its accuracy in the detection of urothelial carcinoma is moderate and it is also an important factor in trophoblast differentiation.

CASE PRESENTATION

A 78-year-old man presented with asymptomatic gross hematuria for 6 months. Cystoscopy and clinical imaging revealed local bladder carcinoma. He underwent a radical cystectomy and histological diagnosis revealed pure choriocarcinoma (pT2aN0M0) with positive immunostaining, indicating GATA-3 was present. Systemic chemotherapy could not be applied due to his poor general condition, and he died 7 months after surgery.

CONCLUSION

We reported the first case of pure choriocarcinoma of the bladder, which showed positive immunostaining results indicating the presence of GATA-3.

The role of a semi-automated NanoVelcro system in capturing circulating tumor cells and evaluating their prognostic value for gestational choriocarcinoma

To investigate whether circulating tumor cells (CTCs) are detectable in patients with gestational choriocarcinoma (GC) and evaluate the prognostic value of CTC enumeration. In this multicenter study, the presence of CTCs was examined in 180 GC patients using a semi-automated NanoVelcro system, among whom 106 patients underwent CTC re-evaluation after one cycle of chemotherapy. Approximately 96% of the GC patients contained ≥2 CTCs in 7.5 mL of blood. The number of CTCs per 7.5 mL of blood was much higher in patients with distant metastases (n = 95; range, 0 to 104) than in patients without distant metastases (n = 85; range, 0 to 6). Applying a 90-patient training and 90-patient validation cohort, a cutoff value of ≥6 CTCs was defined as the prognostic threshold for progression-free survival (PFS) and overall survival (OS). The presence of ≥6 CTCs was significantly associated with worse PFS and OS (both P < 0.001). A multivariate analysis showed that the CTC number (≥6 CTCs) was the strongest predictor of OS (hazard ratio [HR], 15.8; 95% confidence interval [CI], 4.3-57.9; P < 0.001). The number of CTCs decreased after one cycle of chemotherapy; univariate analyses demonstrated that the CTC count after the first chemotherapy cycle was a strong predictor of OS (HR, 36.1; 95% CI, 4.8-271.5; P < 0.001). CTCs are a promising prognostic factor for GC. The absolute CTC count after one cycle of chemotherapy in the context of this disease is a strong predictor of chemotherapy response.

Primary Choriocarcinoma of the Bladder: A Case Report and Review of Literature

Primary choriocarcinoma of the urinary bladder is a rare entity, and should be distinguished from urothelial carcinoma with trophoblastic differentiation. The leading treatment modalities include surgical extirpation, chemotherapy, and radiation; however, survival remains poor. Herein we describe a rare case of choriocarcinoma of the bladder in a man who presented for evaluation with hematuria and subsequently underwent radical cystectomy with urinary diversion. Diagnosis of extragonadal germ cell tumor was confirmed using fluorescence in situ hybridization identification of isochromosome 12p.

Ovarian nongestational choriocarcinoma and associated adenocarcinoma with the same germ cell origin determined by a molecular genetic approach: A case report

Ovarian non-gestational choriocarcinomas co-existing with adenocarcinoma are extremely rare and have been reported as epithelial ovarian carcinomas of a "non-germ cell origin" with "choriocarcinomatous differentiation". Although the cellular origin of non-gestational choriocarcinoma may be post-meiotic ovarian germ cells or the dedifferentiation of epithelial ovarian carcinoma, detailed genetic evidence has not yet been obtained to support this. We herein present a case of ovarian non-gestational choriocarcinoma co-existing with adenocarcinoma in a 29-year-old woman. The tumor rapidly increased in size and lung metastases appeared soon after parturition. We genetically demonstrated that the cellular origin of ovarian non-gestational choriocarcinoma was a post-meiotic germ cell derivation using a short tandem repeat analysis. The co-existing adenocarcinoma component was also shown to be of the same germ cell origin. These tumors showed the same homozygous pattern. A molecular genetic approach may be important for understanding the clinicopathological features of such tumors.

Endometrioid adenocarcinoma with choriocarcinomatous differentiation: A case report and review of the literature

A choriocarcinomatous component is rarely present in carcinomas of certain sites and few cases of choriocarcinomatous differentiation in endometrioid adenocarcinoma have been reported. The present study reports a case of endometrioid adenocarcinoma of the uterine corpus with choriocarcinomatous differentiation, and discusses the clinicopathological features of this rare tumor. A 59-year-old post-menopausal female presented with abnormal vaginal bleeding. Magnetic resonance imaging demonstrated a relatively well-circumscribed tumor in the uterine corpus and a total cystectomy was subsequently performed. A histopathological examination revealed two distinct components in the uterine corpus tumor. The first component comprised ~80% of the tumor and was composed of poorly-differentiated endometrioid adenocarcinoma. The remaining component consisted of mononucleated and syncytial giant cells containing rich eosinophilic cytoplasm and large pleomorphic nuclei with coarse chromatin. An immunohistochemical analysis revealed that these syncytial giant cells were positive for β-human chorionic gonadotropin (hCG). Therefore, a diagnosis of endometrioid adenocarcinoma with choriocarcinomatous differentiation was confirmed. The clinicopathological features of nine previously reported cases of this tumor were analyzed in addition to the present case. The majority of the patients were post-menopausal. Endometrial choriocarcinoma may be considered to have a highly aggressive clinical course, since nine of the 10 cases displayed metastases and four patients succumbed to the disease. The pathogenesis of the choriocarcinomatous component is not well understood. However, genetic studies have demonstrated that conventional carcinoma and choriocarcinomatous components share common genetic alterations. The choriocarcinomatous component represents aberrant differentiation of the conventional carcinoma, however, genetic analyses of endometrioid adenocarcinoma with choriocarcinomatous differentiation have not been performed.

Renal choriocarcinoma: gestational or germ cell origin?

Choriocarcinoma is a rare, highly malignant trophoblastic tumor with gestational or, rarely, germ cell origin. Primary extragenital localization is extremely rare. This report describes a choriocarcinoma case clinically mimicking a primary renal cell carcinoma with multiplex pulmonary metastases. Differentiation from a sarcomatoid renal cell carcinoma with trophoblastic differentiation and identification of the exact origin, namely gestational or germ cell origin by molecular genetic methods is of great importance as it helps determine the prognosis and the most effective therapy of the disease. The Investigator Hexaplex ESS Kit was used for DNA polymorphism studies. This showed foreign alleles in the tumor DNA that confirmed the presence of paternal DNA and the gestational origin of the tumor.

Molecular genetic analyses of choriocarcinoma

BACKGROUND

Choriocarcinoma is a highly malignant trophoblastic neoplasm. Most of them are gestational in origin, while non-gestational ones are exceedingly rare. The genetic origin, immunogenicity, sensitivity to chemotherapy and prognosis of these two kinds of conditions are quite different, so identification of these two kinds of choriocarcinoma is of great importance. The objective of this study is to distinguish choriocarcinoma as gestational or non-gestational and identify the causative pregnancy of gestational choriocarcinoma through molecular genetic analysis.

METHODS

Twelve patients with choriocarcinoma, who had experienced surgery prior to chemotherapy, were enrolled in this study. DNA was prepared from blood samples from the patient and her partner using standard techniques. In order to prepare DNA from choriocarcinoma tissue, areas of choriocarcinoma were firstly microdissected from haematoxylin and eosin-stained sections. PCR amplification and fluorescent microsatellite genotyping were performed using DNA from the couples and captured tissue. The genetic contributions to the choriocarcinoma were determined by comparing the genotypes of the choriocarcinoma and that of the couples.

RESULTS

Four of twelve cases had only a maternal contribution, indicating a non-gestational origin. The remaining eight cases were all gestational in origin and the causative pregnancies were identified as AnCHM (androgenetic complete hydatidiform mole) in six and normal pregnancies in two respectively.

CONCLUSION

Microsatellite polymorphism analysis is a molecular approach for distinguishing the non-gestational choriocarcinoma from the gestational one, and can also be used to identify the causative pregnancy of gestational choriocarcinoma. Antecedent pregnancy prior to choriocarcinoma is not always its causative pregnancy. Therefore, it is reasonable to identify the causative pregnancy by its genetic origin, instead of clinical impression.

Lumbar metastasis of choriocarcinoma

STUDY DESIGN

A case of lumbar metastasis of a choriocarcinoma is presented.

OBJECTIVE

To present and review a rare case of metastatic choriocarcinoma in the lumbar spine.

SUMMARY OF BACKGROUND DATA

Choriocarcinoma is a highly anaplastic malignancy derived from trophoblastic cells characterized by the secretion of human chorionic gonadotropin (hCG) and early hematogenous metastasis. However, metastatic choriocarcinoma in the spine is extremely rare. Although 2 cases of metastasis in lumbar and/or sacral vertebra have been reported, the efficacy of surgical treatment for the spinal metastasis of choriocarcinoma is not yet known.

METHODS

The clinical course, radiologic features, pathology, and outcome of the treatment of metastatic choriocarcinoma of the lumbar spine is reported.

RESULTS

A 38-year-old female patient with abnormal uterine bleeding 6 weeks after a normal-term delivery showed high serum levels of hCG. A whole body image analysis revealed a lesion in the L2 vertebra. After computed tomography-guided needle biopsy, a clinical and pathologic diagnosis of lumbar metastasis of choriocarcinoma was made. Surgical resection of the localized L2 vertebra lesion was performed by total en bloc spondylectomy after a poor response to initial chemotherapy with methotrexate. Postsurgically, the serum level of hCG explosively increased and local recurrences around the original L2 vertebra and epidural metastasis abruptly developed. Lung metastases also occurred concurrently and progressed and the patient eventually died to the disease.

CONCLUSION

We have reported a rare case of lumbar metastasis of choriocarcinoma after a normal-term pregnancy. This is the first report of lumbar metastasis of choriocarcinoma treated by spinal surgery. Because surgical resection of a lumbar metastasis of choriocarcinoma involves a substantial risk of profuse hemorrhage, local recurrence and the spread of metastasis, multiagent chemotherapy in combination with radiotherapy should be preformed before surgical resection.

Male choriocarcinoma with metastasis to the jejunum: a case report and review of the literature

We report on a patient with male choriocarcinoma. The patient was a 31-year-old male patient with jejunal choriocarcinoma that metastasized from the mediastinum. He was admitted complaining of melena and severe anemia. Upper and lower gastrointestinal endosocopy was performed, but no source of bleeding was seen. Chest X-ray and CT revealed a mediastinal tumor 7 cm in size anterior to the arotic arch. Superior mesenteric arteriography showed irregularities and macular opacity in the jejunal artery. An emergency laparatomy was performed because of massive gastrointestinal bleeding. A jejunal tumor approximately 4 cm in size was resected and numerous metastases were observed in the liver and mesentery. Histopathological examination showed metastatic jejunal choriocarcinoma. Gynecomastia was not present and the testes were normal. Serum beta-human chorionic gonadotropin (HCG) was at an abnormally high level of 4,396 ng/mL. Because of metastases to the brain and invasion to the trachea, he died on postoperative day 20. We report this rare case of a male patient with metastases of choriocarcinoma to the gastrointestinal tract from the mediastinum, together with a review of the literature.

Urothelial carcinoma with plasmacytoid variants producing both human chorionic gonadotropin and carbohydrate antigen 19-9

Plasmacytoid urothelial carcinoma is a rare malignant neoplasm in the urinary bladder. A 46-year-old man presented with gross hematuria and increased serum concentrations of both carbohydrate antigen (CA) 19-9 and beta-human chorionic gonadotropin (beta-hCG). The tumor was composed of conventional urothelial carcinoma and plasmacytoid variant, both positive for epithelial markers. In addition, plasmacytoid tumor cells were positive for an accepted marker of plasma cell origin, CD138. CA19-9 was mainly expressed in conventional urothelial carcinoma cells, and beta-hCG was mainly produced by plasmacytoid tumor cells. This is the first report, to our knowledge, indicating beta-hCG can be produced by plasmacytoid bladder cancer cells lacking trophoblastic features.