Rectal adenocarcinoma with germ cell elements treated with chemotherapy

Primary Rectal Tumor With Extensive Choriocarcinoma Differentiation in a Woman With Lung, Liver and Disseminated Peritoneal Disease: A Primary Rectal Adenocarcinoma With Extensive Choriocarcinoma Differentiation or Primary Rectal Choriocarcinoma?

Primary rectal adenocarcinoma with extensive choriocarcinomatous differentiation is a rare neoplasm, with only sporadic cases reported worldwide. The prognosis is typically poor, and no standard therapy has been established for this tumor. We report a case of a 63-year-old woman who presented with lower abdominal and pelvic discomfort, as well as rectal bleeding. Endoscopy revealed a rectal tumor. She was diagnosed with primary rectal adenocarcinoma with extensive choriocarcinomatous differentiation, accompanied by liver metastasis and peritoneal carcinomatosis. The immunohistochemical profile demonstrated strong and diffuse positivity for keratin (AE1/AE3), beta-human chorionic gonadotropin (β-HCG), p53, MYC, p16, and Ki-67. Molecular analysis indicated mutations in KRAS, TP53, and PI3KCA. Despite the tumor's profile, the serum β-HCG level was not elevated. A chemotherapy regimen for metastatic colorectal adenocarcinoma was initiated, but there was a poor response, with rapid tumor progression. The patient survived for only 5 months postdiagnosis. We discuss the histopathological, immunohistochemical, and molecular findings, emphasizing their relevance to the differential diagnosis of neoplasms with choriocarcinomatous differentiation.

Histologic transformation of rectal adenocarcinoma to choriocarcinoma after surgery and chemotherapy: A rare case report and review of the literature

INTRODUCTION AND IMPORTANCE

Choriocarcinoma is a rapidly progressive, widely metastatic, β-human chorionic gonadotropin (β-hCG)-secreting malignant tumor originating from trophoblast cells. Most choriocarcinomas are pregnancy-related. Choriocarcinoma of nonpregnant origin is very rare.

CASE PRESENTATION

A 60-year-old woman underwent abdominopelvic resection (APR) for low rectal cancer in May 2020. Postoperative pathological findings showed a poorly differentiated adenocarcinoma. Because of a post-operative recurrence, then she underwent chemotherapy for rectal adenocarcinoma. In February 2021, imaging finding showed metastases in her liver, both lungs and pelvis. Surprisingly, the β-hCG level was significantly elevated. A transvaginal pelvic tumor biopsy was performed and the pathology report was presented after discussions: choriocarcinoma differentiated carcinoma was considered, with no adenocarcinoma component detected. Then the patient underwent chemotherapy regimens for choriocarcinoma, which were initially effective but quickly became resistant. The patient died 8 months after the diagnosis of adenocarcinoma of the rectum transformed into choriocarcinoma.

CLINICAL DISCUSSION

The dedifferentiation of adenocarcinoma to choriocarcinoma is rarely diagnosed and the disease is often overlooked, leading to delays in diagnosis and treatment, documenting cases and their clinical outcomes is important for future research and to improve patient prognosis. Perhaps genomic assessment using next-generation sequencing (NGS) technology could help in diagnosis and guide therapeutic strategies.

CONCLUSION

We report a very rare case of non-pregnant choriocarcinoma transformed from primary rectal adenocarcinoma. Awareness of secondary biopsies in special cases and genetic testing based on the dynamics of the disease should be raised in clinical practice to better develop precise treatment plans.

Yolk Sac Tumor in a Recurrence of Colonic Adenocarcinoma With Shared Mutations in APC and TP53 Genes: A Case Report

Only four cases of colorectal adenocarcinoma with a yolk sac tumor (YST) component have been reported in the English literature. No genetic investigation has been performed in these cases. We report a case of colorectal adenocarcinoma in which the recurrent tumor had a YST component. A 49-year-old woman presented with a pelvic tumor three years after endoscopic mucosal resection of sigmoid colon adenocarcinoma. The pelvic tumor consisted of an undifferentiated carcinoma component and a YST component. The serum alpha-fetoprotein level was elevated to 42 ng/mL. Treatment as conventional colorectal carcinoma produced some anticancer effects, but the patient died 14 months after the recurrence and 49 months after the EMR. With the help of the next-generation sequencing results of the recurrent tumor, APC c.835 - 8A > G and TP53 c.524G > A (p.R175H) mutations were identified by direct sequencing in both the primary and the recurrent tumors, confirming the relationship between the two metachronous tumors.

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.

Germ cell tumor of the colon with an adenocarcinomatous component

A case of combined germ cell tumor and adenocarcinoma that arose in the colon of a 62-year-old man is described. The clinical and pathological findings are presented. The patient had widespread metastases at diagnosis and poor prognosis after operation (right hemicolectomy) was performed in spite of receiving chemotherapy. Pathologically, the germ cell tumor was composed of a yolk sac tumor and choriocarcinoma. Further, all the metastatic lesions showed a germ cell phenotype. An extragonadal germ cell tumor is extremely rare. To our knowledge, only a few cases have been reported in the English-language literature. Our present report will contribute to the understanding of the characteristics of this rare neoplasm.

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.

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.

Ovarian endometrioid tumors with yolk sac tumor component, an unusual form of ovarian neoplasm. Analysis of six cases

The clinical, morphological, and immunohistochemical findings in six cases of ovarian endometrioid tumors (five endometrioid carcinomas and one carcinosarcoma) with a yolk sac tumor (YST) component are described. The age of the patients ranged from 31 to 73 years (average, 53), and only two patients were premenopausal. Two cases were stage Ia tumors, three stage III, and one stage IV. A substantial postoperative elevation of alpha-fetoprotein (AFP) was seen in two patients and a mild increase in another two. All six patients had surgery and postoperative cisplatin-based chemotherapy regimens, four of whom died of tumor 3 to 14 months after surgery without response to treatment. Only a stage Ia patient is alive and well 1 year after surgery. The tumors were large (average, 17 cm). Benign endometrioid lesions were found in the homolateral ovary in two cases and in the contralateral ovary in another two. All cases had endometrioid ovarian carcinomas (EOC) of various types admixed with typical YST components. Immunohistochemically, EOC areas differed from YST in their positivity for OC 125, CA 19.9, and nuclear estrogen and progesterone receptors and in their negativity for AFP, which was conspicuously positive in the YST areas. The clinicopathological profile of ovarian endometrioid tumors with YST also differs from that of YST in that it occurs in the same age range as EOC, it shows coexistence of benign endometrioid lesions, and it has a poor response to chemotherapy. The histological pattern in transitional areas may be difficult to differentiate from "endometrioid-like" (enteroblastic) YST and clear cell tumors. Ovarian endometrioid tumors with YST component should be considered a variant of endometrial carcinoma. Its recognition is necessary in view of its unusually aggressive behavior and poor prognosis.

Alpha-fetoprotein-producing adenocarcinoma of the sigmoid colon with possible hepatoid differentiation

A patient with adenocarcinoma of the sigmoid colon producing alpha-fetoprotein (AFP) is described. Hepatoid differentiation is suggested by the morphological appearance and production of hepatic-type AFP. The possible histogenesis of such a tumor is discussed.