Cervicoisthmic choriocarcinoma mimicking cesarean section scar ectopic pregnancy
In August 2012, a 30-year-old Chinese woman was admitted to Pescia Hospital for irregular vaginal bleeding of 10 days duration and sovrapubic pain.\nShe was gravida 4 para 2. Her first and third pregnancy ended in full term delivery by cesarean section (C-section) at 40 and 39 gestational week respectively. Her second and last pregnancy ended in the first trimester abortion in 2007 and 2010 respectively.\nAfter 17 weeks of amenorrhea, serum beta human chorionic gonadotropin (β-hCG) was 40796 mUI/ml. Trans-vaginal ultrasound scan failed to identify an intrauterine pregnancy and showed the presence of an extremely vascularized cervical mass, localized in the isthmic region of the cervix, just over the scar of the previous C-section. The patient was considered to have an ectopic cesarean scar pregnancy and then was referred to our clinic, Careggi University Hospital as a third level hospital, for a better diagnostic and therapeutically assessment.\nWe repeated trans-vaginal ultrasound scan that confirmed the diagnosis [Figures and ]. Serum β-hCG level continued to grow reaching the value of 60,000 mUI/dl in 3 days. The patient had no any other symptoms than little vaginal bleeding.\nSince, there is no standard protocol in the treatment of cesarean scar pregnancy, we discussed with the patient three treatment options: Expectant management, medical therapy or conservative surgical therapy. The decision fell on surgery and the patient underwent explorative laparotomy. The cervical lesion appeared as a large, friable highly vascularized mass that occupied the whole thickness of cervical wall. Intra-operative conversion to hysterectomy became necessary since the unfeasibility of conservative uterine surgery. The patient made an uneventful recovery. She was discharged on postoperative day 4, with serum β-hCG of 4885 mUI/ml.\nDefinitive pathologic evaluation of surgical specimen led to the diagnosis of: Primary gestational cervical choriocarcinoma with the presence of syncitiotrophoblastic and cytotrophoblastic cells [Figures and ]. Imunohistochemical staining was positive for β-hCG.\nNo metastases were detected by post-surgical whole-body computed tomography (CT).\nThe FIGO (Fédération Internationale de Gynécologie et d’Obstétrique) 2000 criteria showed a stage I choriocarcinoma (confined to the uterus) with a FIGO score of 8:[] Abortion before choriocarcinoma (1 point), delay between pregnancy and choriocarcinoma of over 12 months (4 points), and β-hCG blood level of between 10,000 and 100,000 (2 points), largest tumor size of 3, 7 cm (1 point).\nAccording to the FIGO classification, the patient began a combination chemotherapy using etoposide, methotrexate, actinomycin D, alternating with cyclophosphamide and oncovine (EMA-CO).\nAfter the first cycle of chemotherapy, the serum β-hCG decreased to normal range (<5 mUI/dl). Eight weeks after the β-hCG level was still negative and treatment ended with the third cycle of EMA-CO.\nOne month later whole body CT scan revealed no abnormality.