Introduction
Choriocarcinoma may develop during any form of gestation: abortion or tubal pregnancy, term or preterm gestation, or hydatidiform moles. Clinical follow-up is considered to be essential due to the high risk of metastases. Outside the pelvis, lung metastases are relatively common, occurring in 80% of cases; brain metastases are relatively uncommon (10%) [
1]. Here we report a rare case of a young pregnant woman (gravida 3, para 0) with choriocarcinoma brain metastasis in the 28th gestational week. The aim of this report was to present this rare case and discuss the management of choriocarcinoma with brain metastasis.
Case report
A 25-year-old Chinese woman in her 28th week of pregnancy was admitted to the local hospital with a complaint of severe and unremitting headaches, nausea, and vomiting. The patient was given metoclopramide (dose 10 mg) by intramuscular injection to alleviate her symptoms, with no effect. She was then transferred to Jiaxing Maternity and Child Health Care Hospital. After admission, she presented sudden convulsion, aconuresis, and unconsciousness. Blood pressure, pulse, and temperature were 90–100/60–70 mmHg, 90–100 bpm, and 36.7–37 ℃, respectively. The patient was administered intravenous mannitol (1 g/kg over a 15-min period).
The patient’s medical history revealed that her last pregnancy was terminated by artificial abortion in August 2017. There had also been one previous artificial abortion 3 years earlier. After the last artificial abortion, the patient's menstrual cycle was regular, and there was no irregular uterine bleeding. The patient had no other special family, medical, and surgical history. After leaving college, she worked as a secretary and she was registered as a resident of Jiaxing Zhejiang. The patient had never smoked or consumed alcohol.
Discussion
Metastatic choriocarcinoma in a patient at a late stage of pregnancy is extremely rare. It is more likely to be associated with hydatidiform moles, and even then only 2–3% of hydatidiform moles progress to choriocarcinoma [
1]. Our patient presented with severe and unremitting headaches, nausea, and vomiting, all typical systems of choriocarcinoma. The CT scans of the brain and lungs were highly suspicious of pulmonary tuberculosis metastasis; however, the preliminary diagnosis was a misdiagnosis. Fortunately, sequential management of the patient was not delayed. We observed a significant rise in the level of β-HCG. A background search of the patient's menstrual and obstetrical history revealed that the last artificial abortion was mild trophoblastic hyperplasia. The patient did not have a follow-up examination of HCG level. It was considered that trophoblastic hyperplasia evolved into choriocarcinoma in the current pregnancy. Pathological examination of the brain hemorrhagic mass supported the diagnosis of choriocarcinoma.
Yang
et al. [
2] reported a case of gestational choriocarcinoma misdiagnosed as pulmonary tuberculosis in a patient who had no abnormal uterine bleeding. When a patient presents with multiple pulmonary nodules, brain multiple mass, or other viscera multiple mass, we must consider choriocarcinoma, whether the patient is pregnant or not, whether or not menstruation has ceased, and whether or not there is irregular vaginal bleeding. The doctor should take note of serum β-HCG levels and obstetrical history.
Mamelak
et al. reported a case of choriocarcinoma brain metastasis in a patient in her 30th week of pregnancy [
3]. The patient was treated with surgical removal of the brain metastasis and a cesarean section. We also performed caesarean section and craniotomy, hematoma clearance, and decompression simultaneously in our patient, and surgically removed a significant mass of brain metastasis. It was noted in our patient that when the brain mass grows progressively, neurological symptoms deteriorate promptly.
Chemotherapy offersa cure to 80% of choriocarcinoma metastases, even those to the lung, brain, or other any body part [
4]. One case report showed that a patient with metastatic choriocarcinoma treated with EMACO chemotherapy achieved satisfactory clinical prognosis [
5]. Yu
et al. reported a case of patient with metastatic choriocarcinoma who required combination chemotherapy as EP/EMA (toposide, methotrexate, and dactinomycin) [
6]. Mamelak
et al. reported a case of brain metastatic choriocarcinoma that was treated with brain radiotherapy and chemotherapy within 1 week after surgery [
3]. Brain metastatic choriocarcinoma requires multidrug combined therapy, including craniotomy, whole brain radiotherapy, and EP-EMA or EMA-CO chemotherapy [
7]. However, the effectiveness of radiotherapy is still debatable. In our case, the patient was very satisfied with her recovery on the EP and EMACO regimens.
We searched PUBMED and Web of Knowledge for studies on intrauterine pregnancy associated with brain metastatic choriocarcinoma. We found that choriocarcinoma brain metastasis presented between 28 and 32 weeks of pregnancy [
3,
6,
8,
9]. Lorna
et al. [
8] reported a case of metastatic choriocarcinoma in which the initial CT of the brain was negative for any lesions in the 20th week of intrauterine pregnancy. The patient developed intracranial metastases after the induction of labor at 32 weeks of gestation. The time to development of brain metastasis was unknown.
Conclusions
Gestational choriocarcinoma in a third trimester pregnancy is rare, but metastatic lesions are numerous. If an intracranial mass or bilateral pulmonary nodules are found in a pregnant woman, especially during the third trimester, metastatic choriocarcinoma should be considered.
Acknowledgements
Not applicable.
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