Abstract:
A 42-year-old woman (G3P1A2) presented to the E.R. with persistent metrorrhagia. The patient had a history of spontaneous abortion without further follow up. The lab results showed a positive pregnancy test with a significantly elevated β-hCG (6417 U/L).
Assessment of the pelvic examination showed vaginal bleeding with no other positive finding. The gynecological ultrasound showed a normal sized uterus with slightly heterogeneous myometrium and enlarged right ovary with cysts. Considering the differential diagnosis of ectopic pregnancy and a malignancy secreting β-hCG, the patient underwent an exploratory abdominal laparoscopy with endometrial biopsy that had no pathological
findings.
As the patient mentioned an episode of dizziness and there was a high suspicion of a malignancy secreting β-hCG, it was decided to continue the evaluation with a brain Magnetic Resonance Imaging (MRI) and a chest Computed Tomography (CT) scan. The chest CT scan (Fig 1) showed a heterogeneous pulmonary mass in the inferior right lobe and the brain MRI (Fig 2) revealed a space-occupying lesion in the left cerebellar hemisphere. The patient underwent a surgical resection of the cerebellar lesion and the anatomic pathology results were indicative of Choriocarcinoma.
Discussion:
Choriocarcinoma is a rare, aggressive neoplastic type of trophoblastic disease, which may occur after miscarriage, abortion, ectopic pregnancy or term pregnancy.
Elevated β-hCG levels in a woman without confirmed intrauterine pregnancy should prompt a search for both ectopic pregnancy and the possibility of a malignancy secreting β-hCG. The main risk factors are History of hydatidiform mole or ectopic pregnancy; A blood type; smoking; extremes of maternal age and Long-term oral contraceptive use.
High clinical suspicion should be maintained for choriocarcinoma in women with hemoptysis and molar pregnancy, current, or recent pregnancy, or irregular vaginal bleeding.
Pulmonary metastases can cause cough, hemoptysis, or chest pain. In brain metastases, headaches, paresthesia, or seizures may occur.
Trophoblastic cells possess an affinity for blood vessels; therefore, trophoblastic tumors exhibit a tendency to metastasize via the hematogenous route being the lungs (80%) and brain (20%) the most frequent metastases. That´s the main reason why MR imaging of the brain and CT of the chest and abdomen are indicated when Choriocarcinoma is suspected.
