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Zribi A, Mazroui RA, Sayani R, Burney IA. An Unusual Presentation of Choriocarcinoma in a Postmenopausal Woman: A case report. Sultan Qaboos Univ Med J 2024; 24:135-138. [PMID: 38434469 PMCID: PMC10906773 DOI: 10.18295/squmj.5.2023.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/14/2023] [Accepted: 04/19/2023] [Indexed: 03/05/2024] Open
Abstract
Choriocarcinoma (CC) is a malignant neoplasm of the trophoblastic tissue, with a potential to metastasise to distant organs. Limited case of gestational CC develops after a long latent period. We report a 52-year-old postmenopausal woman who developed metastatic choriocarcinoma presumably of gestational origin, 8 years after the last pregnancy and 2 years after the last menstrual period. The patient was brought to the emergency room of a tertiary care centre in Muscat, Oman, in 2022 and was diagnosed with CC metastatic to the brain, spleen, lung and the kidney. The β-human chorionic gonadotrophin level was found to be raised (1,292,867 mIU/mL). The International Federation of Gynecologic Oncology risk score was calculated to be 14 (very high risk). The patient was initially treated with whole-brain radiotherapy and splenic artery embolisation because of a hemoperitoneum. Afterwards the patient received systemic treatment using the standard EMA/CO regimen till complete serological remission.
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Affiliation(s)
| | - Reem Al Mazroui
- Department of Radiology, Sultan Qaboos Comprehensive Cancer Care and Research Centre, Muscat, Oman
| | - Raza Sayani
- Department of Radiology, Sultan Qaboos Comprehensive Cancer Care and Research Centre, Muscat, Oman
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An Unusual Presentation of Choriocarcinoma: A Case Report with a Long Latent Period. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.103802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Choriocarcinoma (CC) is a rare malignant tumor of trophoblastic tissue. This tends to invade rapidly to the vasculature and metastasis to the lung, vagina, brain, and liver. CC can present with a variety of manifestations, such as hemoptysis, gastrointestinal (GI) bleeding, and abnormal uterine bleeding. Commonly, the latent period to the development of CC is not more than 1 year after the antecedent molar or normal pregnancy. In this report, the patient developed CC about 32 months after her previous known pregnancy. We reported a rare case of gestational CC that occurred about 32 months after her antecedent pregnancy. Case Presentation: A 21-year-old admitted in shock with abnormal uterine bleeding, pain, and lower abdominal pain. The patient had one previous cesarean section 32 months prior to admission. The vaginal examination demonstrated a fused solid cervical mass with an irregular border measuring about 7 × 7 cm. In further workup, there was evidence of a 103 × 94 × 89 mm mass with the hemorrhagic area and central necrosis in the middle and lower segments of the uterus and cervix. The patient underwent a total abdominal hysterectomy and left side salpingo-oophorectomy. The diagnosis of CC was made after microscopic examination. Conclusions: There are few case reports of choriocarcinoma with more than a year latent period after antecedent pregnancy. The strongest hypothesis is having asymptomatic pregnancy during the period between the last pregnancy and the development of CC. However, the possibility of non-gestational choriocarcinoma in such cases should be considered. Treatment with a single- or multiple-agent chemotherapy regimen should be immediately initiated after diagnosis in these cases.
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El Hasbani G, Balaghi A, Tarabine K, Assaker R, Samaha M, Ghanem H, Bejjani N, Abouzeid B. Uterine choriocarcinoma diagnosed 11 years after menopause: A case report. Case Rep Womens Health 2018; 20:e00076. [PMID: 30263892 PMCID: PMC6156800 DOI: 10.1016/j.crwh.2018.e00076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/03/2018] [Accepted: 09/07/2018] [Indexed: 11/16/2022] Open
Abstract
Background Gestational trophoblastic neoplasms (GTNs) encompass a wide spectrum of diseases, of which choriocarcinoma is one of the most common. Choriocarcinoma occurs mainly in relation to pregnancy and rarely after the menopause. It has the potential to metastasize to organs other than the uterus. Case Report We describe a 62-year-old woman who presented with postmenopausal bleeding 11 years after the menopause. Pelvic ultrasound and abdominal/pelvic computerized tomography showed an intrauterine mass. Choriocarcinoma was diagnosed by Pipelle endometrial biopsy with positive staining for beta-human chorionic gonadotropin (hCG) and KI 67 along with an elevated serum beta-hCG level. The tumor was managed with multiple cycles of multidrug chemotherapy and follow-up based on serum beta-hCG levels according to the guidelines of the International Federation of Gynecology and Obstetrics (FIGO). Conclusion This case report highlights that choriocarcinoma, a tumor normally associated with pregnancy, can present after the menopause.
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Affiliation(s)
| | - Alaa Balaghi
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | - Kamal Tarabine
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | | | - Michel Samaha
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | - Hadi Ghanem
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | - Noha Bejjani
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | - Bassel Abouzeid
- Lebanese American University Medical Center, Ashrafieh, Lebanon
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Mangla M, Singla D, Kaur H, Sharma S. Unusual clinical presentations of choriocarcinoma: A systematic review of case reports. Taiwan J Obstet Gynecol 2017; 56:1-8. [PMID: 28254207 DOI: 10.1016/j.tjog.2015.05.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2015] [Indexed: 12/20/2022] Open
Abstract
Choriocarcinoma (CC) is a highly malignant tumor originating in the trophoblastic tissue. The clinical presentation of CC is so much varied that every case may be one of its kinds and thus can be a diagnostic challenge. Numerous case reports have been published in various journals regarding the unusual clinical presentations of this cancer. Therefore, we conducted a systematic review of all case reports in English language on gestational CC published in PubMed-indexed journals from 1998 to 2015. The main aim was to provide a summary and critical analysis of all the data and evidence published regarding the atypical clinical presentations of CC in recent years. In total, 121 case reports pertaining to unusual clinical manifestations of gestational CC were analyzed. The age of patients in whom cases were reported ranged from 17 to 67 years, and the time period between the index pregnancy and development of CC varied from 4 weeks to as long as 25 years. Cardiopulmonary complaints (20.66%) followed by gastrointestinal (18.43%) and central nervous system manifestations (17.67%) were found to be the most common. Through this review, the authors have made an attempt to discuss various manifestations with which a patient with gestational CC can present to clinician so that early diagnosis and timely management can be initiated, thus improving clinical prognosis.
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Affiliation(s)
- Mishu Mangla
- Department of Gynecology and Obstetrics, GianSagar Medical College and Hospital, Banur, Punjab, India.
| | - Deepak Singla
- Department of Anesthesia, BPS Govt. Medical College, Khanpur Kalan, Sonipat, Haryana, India
| | - Harpreet Kaur
- Department of Gynecology and Obstetrics, GianSagar Medical College and Hospital, Banur, Punjab, India
| | - Sushmita Sharma
- Department of Gynecology and Obstetrics, GianSagar Medical College and Hospital, Banur, Punjab, India
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Li HM, Hou WC, Lai YJ, Kao CC, Chao TK, Yu MH, Su HY. Gestational choriocarcinoma with renal and pulmonary metastases lacking a primary uterine origin. Taiwan J Obstet Gynecol 2017; 55:881-885. [PMID: 28040140 DOI: 10.1016/j.tjog.2015.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe a case of gestational choriocarcinoma metastasized to the kidney and lung, which presented initially as refractory hematuria after a term pregnancy 5 years earlier. CASE REPORT A 35-year-old woman, G2P1, with a previous history of full-term pregnancy in 2009, presented to the emergency department complaining of intermittent gross hematuria for 2 months. Abdominal computed tomography showed a suspicious arteriovenous malformation in the right kidney and a thrombus within the right renal vein. Transarterial embolization was performed twice to treat the refractory hematuria but was unsuccessful, and radical nephrectomy of the right kidney was performed. The diagnosis was gestational metastatic choriocarcinoma of the kidney based on morphological, immunohistochemical, and DNA studies. Lung metastases were found by computed tomography of the chest. Pelvic ultrasound was performed but showed no primary tumor in the uterine cavity. After surgical intervention, adjuvant chemotherapy involving first single-agent chemotherapy with methotrexate followed by multiagent chemotherapy (EMACO regimen) failed. CONCLUSION In women of reproductive age, unexplained hematuria should raise concerns about possible choriocarcinoma, either metastatic gestational or primary nongestational choriocarcinoma of the kidney.
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Affiliation(s)
- Hao-Ming Li
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Chien Hou
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Ju Lai
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Chang Kao
- Section of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tai-Kuang Chao
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Mu-Hsien Yu
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Her-Young Su
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Rojas Arellano ML, Carmona Ornelas VH, García Bahena M, Muñoz Cortés SB, Pérez-Calatayud ÁA. Coriocarcinoma durante la perimenopausia: reporte de un caso. GACETA MEXICANA DE ONCOLOGÍA 2016. [DOI: 10.1016/j.gamo.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Arteriovenous Fistula Embolization in Suspected Parauterine Choriocarcinoma. Case Rep Obstet Gynecol 2016; 2016:6353471. [PMID: 27403360 PMCID: PMC4923520 DOI: 10.1155/2016/6353471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 11/17/2022] Open
Abstract
This is a case of choriocarcinoma that did not regress after chemotherapy treatment. A 30-year-old female patient (gravida 2, para 2), presented to our ER with stroke and persistent mild pelvic pain 2 months after a Caesarean section. Computed tomography (CT) revealed an ischemic left hemicerebellar region and a hypervascular mass in the pelvic region. This mass was not present on routine fetal ultrasound during pregnancy. The lesion was treated by chemotherapy after closure of a foramen ovale and insertion of an inferior vena cava (IVC) filter. After that, 2 courses of EMACO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, and Vincristine) chemotherapy regimen were given. Posttreatment CT showed the hypervascular mass without any changes. Arteriography showed the arteriovenous fistulae that were embolized successfully with plugs, coils, and glue. Embolization was considered due to the risk of acute hemorrhagic life-threatening complications. Eight chemotherapy courses were added after embolization. Treatment by endovascular approach and reduction of the hypervascular mass can be a valuable adjunct to chemotherapy treatment of choriocarcinoma.
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Abstract
Choriocarcinoma is a highly malignant epithelial tumor originating from trophoblast. It primarily occurs during the fertile period. Postmenopausal uterine choriocarcinoma is very rare. We present a case of choriocarcinoma in a postmenopausal lady developing 5 years after menopause. She presented with heavy postmenopausal bleeding along with passage of vesicles per vaginum. Serum beta-hCG was 96,484 mIU/ml. Emergency abdominal hysterectomy with bilateral salpingo-ooperectomy was done due to intractable bleeding following suction and evacuation. Histopathology revealed uterine choriocarcinoma. She was treated with EMACO regimen following which her beta-hCG returned to normal in five cycles. The patient is under regular follow-up and is doing well.
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Affiliation(s)
- Sunil K Samal
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Setu Rathod
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Seetesh Ghose
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
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Xie C, Zheng L, Li ZY, Zhao X. Spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin after chemotherapy. Med Princ Pract 2011; 20:570-3. [PMID: 21986018 DOI: 10.1159/000330028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 02/14/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report an extremely rare case of spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin (β-hCG) post-chemotherapy. CLINICAL PRESENTATION AND INTERVENTION We present a 35-year-old choriocarcinoma patient whose serial serum β-hCG levels following a fifth course of chemotherapy had been within the normal range, but who developed spontaneous uterine perforation with intra-abdominal hemorrhage after eight courses of combined chemotherapy. The patient then underwent an emergency hysterectomy and survived. CONCLUSION Patients with persistent focus of disease in the uterus might experience uterine perforation even after adequate chemotherapy, and therefore, the follow-up for patients after chemotherapy is very important.
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Affiliation(s)
- Chuan Xie
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, PR China
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Desai NR, Gupta S, Said R, Desai P, Dai Q. Choriocarcinoma in a 73-year-old woman: a case report and review of the literature. J Med Case Rep 2010; 4:379. [PMID: 21108779 PMCID: PMC3002375 DOI: 10.1186/1752-1947-4-379] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 11/25/2010] [Indexed: 01/11/2023] Open
Abstract
Introduction Choriocarcinoma is a highly malignant tumor of trophoblastic origin. Most cases present within one year of the antecedent pregnancy (molar or non-molar). However, very rarely, choriocarcinoma can develop from germ cells or from dedifferentiation of endometrial carcinoma into choriocarcinoma. This article concerns a case of choriocarcinoma developing 38 years after the patient's last pregnancy and 23 years after menopause. Case presentation A 73-year-old African-American woman presented with a three-week history of vaginal bleeding. A vaginal mass was seen on pelvic examination. Ultrasonography showed a thickened complex endometrial echo. Her β-human chorionic gonadotrophin level was found to be elevated (2,704,040 mIU/mL). Vaginal and uterine biopsies were suggestive of choriocarcinoma. Immunohistochemistry tests were positive for β-human chorionic gonadotrophin as well as cytokeratin and negative for octamer binding transcription factor 3/4 and α-fetoprotein, supporting the diagnosis of choriocarcinoma. A combination of etoposide, methotrexate, and dactinomycin, followed by cyclophosphamide and vincristine (the so-called EMA/CO regimen) was initiated. After seven cycles of chemotherapy, her β-human chorionic gonadotrophin level dropped below 5 mIU/mL. Our patient is being followed up at our oncology institute. Conclusions We report an extremely rare case of choriocarcinoma arising 23 years after menopause. A postmenopausal woman presenting with vaginal bleed from a mass and β-human chorionic gonadotrophin elevation should be evaluated by immunohistochemical analysis to rule out the possibilities of a germ cell origin of the tumor or dedifferentiation of an epithelial tumor. Absence of octamer binding transcription factor 3/4, α-fetoprotein and CD-30 staining helps in exclusion of most germ cell tumors. DNA polymorphism studies can be used to differentiate between gestational and non-gestational tumor origin. These require fresh tissue samples and are time consuming. Finally, the effective first-line therapy for β-human chorionic gonadotrophin-producing high-risk gestational as well as non-gestational trophoblastic tumors is combination chemotherapy (the EMA/CO regimen). Therefore, treatment should be commenced when a potential diagnosis of metastatic trophoblastic tumor is being considered.
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Affiliation(s)
- Nisarg R Desai
- Department of Medicine, Staten Island University Hospital, Staten Island, New York, USA.
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11
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Acute abdomen as initial presentation of gestational choriocarcinoma. Arch Gynecol Obstet 2009; 280:859-62. [DOI: 10.1007/s00404-009-0968-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Accepted: 01/27/2009] [Indexed: 10/21/2022]
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O'Neill CJ, Houghton F, Clarke J, McCluggage WG. Uterine gestational choriocarcinoma developing after a long latent period in a postmenopausal woman: the value of DNA polymorphism studies. Int J Surg Pathol 2008; 16:226-9. [PMID: 18417687 DOI: 10.1177/1066896907307038] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reports a uterine gestational choriocarcinoma arising in a 57-year-old woman with a long latent period of 22 years from the last known pregnancy. Diagnosis was made on an endometrial biopsy specimen, and given the age of the patient, the long latent period, and the limited sample, trophoblastic differentiation within an endometrial carcinoma was considered. The results of DNA polymorphism studies illustrated both paternal and maternal alleles within the tumor in equal amounts, confirming the neoplasm to be gestational in origin and to have originated from a nonmolar gestation. The report discusses the value of DNA polymorphism studies in distinguishing gestational from nongestational choriocarcinoma and from trophoblastic differentiation within a carcinoma.
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Affiliation(s)
- Ciaran J O'Neill
- Department of Pathology, Royal Group of Hospitals Trust, Belfast, Northern Ireland
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Golfier F, Labrousse C, Frappart L, Mathian B, Guastalla JP, Trillet-Lenoir V, Hajri T, Schott AM, Raudrant D. Évaluation de la prise en charge des tumeurs trophoblastiques gestationnelles enregistrées au Centre de référence des maladies trophoblastiques de Lyon de 1999 à 2005. ACTA ACUST UNITED AC 2007; 35:205-15. [PMID: 17336125 DOI: 10.1016/j.gyobfe.2006.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Accepted: 12/22/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of this study was both to analyse if gestational trophoblastic neoplasia (GTN) registered to the French Trophoblastic Disease Reference Center (TDRC) in Lyon (France) were managed according to the FIGO criteria for diagnosis of GTN and if chemotherapy was adapted to the 2000 FIGO prognostic scoring system. PATIENTS AND METHODS Retrospective, descriptive analysis of 167 GTN registered to GTC of Lyon between 1999 and 2005. RESULTS On the one hand, 66% of women (104/158) had a diagnosis of GTN according to FIGO criteria. One third (n=54) of the patients therefore had a premature or erroneous diagnosis of a tumor, when the treatment started. No supporting element of this premature diagnosis has been found out for 26 patients. The identification of lung and vaginal metastasis and histological diagnosis of invasive mole appeared as the most mentioned inappropriate criteria for diagnosis. On the other hand, chemotherapy was adapted to 2000 FIGO scoring in 91, 5% of cases. Twelve low risk GTN were treated with polychemotherapy and two high risk GTN were treated with monochemotherapy. Moreover 29% of the patients received a non adequate treatment due to deviations from the recommended protocol. DISCUSSION AND CONCLUSION Non respect of FIGO criteria for the diagnosis of GTN can lead to erroneous diagnosis of tumors. Identification of lung or vaginal metastasis or diagnosis of invasive mole should not automatically justify the diagnosis of gestational trophoblastic neoplasia if the decrease in HCG occurs properly. Respect of FIGO criteria for the diagnosis of GTN and adaptation of chemotherapy to 2000 FIGO scoring are necessary to avoid inadequate treatment of gestational trophoblastic neoplasia.
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Affiliation(s)
- F Golfier
- Service de Gynécologie-Obstétrique, Centre de Référence des Maladies Trophoblastiques, Hôtel-Dieu, 1, place de l'Hôpital, 69002 Lyon, France
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Behtash N, Ansari S, Sarvi F. Successful pregnancy after localized resection of perforated uterus in choriocarcinoma and a literature review. Int J Gynecol Cancer 2006; 16 Suppl 1:445-8. [PMID: 16515643 DOI: 10.1111/j.1525-1438.2006.00367.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Choriocarcinoma is an aggressive neoplasm arising in the body of the uterus. Rapid growth and myometrial invasion may be followed by uterine perforation. In this study, we present the cases of two young patients (18 and 19 years of age) with acute abdominal pain and shock, while they were under chemotherapy due to persistent trophoblastic disease. During emergent exploratory laparotomy, localized resection of uterus was performed. They had their first successful term pregnancy 5 and 4 years after surgery, respectively. Uterine perforation following choriocarcinoma is a rare event. Hysterectomy is recommended in emergency conditions, but localized resection of uterus should be considered in women who are desirous of future fertility.
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Affiliation(s)
- N Behtash
- Gynecology Oncology Department, Tehran University of Medical Sciences, Vali Asr Hospital, Tehran, Iran.
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Okamoto, Nomura, Nakanishi, Goto, Tomoda, Mizutani. Choriocarcinoma diagnostic score: A scoring system to differentiate choriocarcinoma from invasive mole. Int J Gynecol Cancer 1998. [DOI: 10.1046/j.1525-1438.1998.97116.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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