Clinical Outcome of a FIGO Stage IV Gestational Choriocarcinoma
In October 2012, a 37-year-old female patient presented with a 7-day history of lower abdominal pain, vaginal bleeding and a raised β-hCG level (44,565 IU/l). In anamnesis, she had two normal antecedent term pregnancies. Within 1 year after the second pregnancy, choriocarcinoma developed. In December 2010, the patient was treated for choriocarcinoma with lung metastasis with three courses of EMACO chemotherapy. Hysterectomy with preservation of the adnexa was performed. In May 2011, she developed clinical manifestations of brain metastasis, which was treated successfully through surgery (extirpation of the tumor in the parieto-occipital region of the brain), radiotherapy and 4, 5 and 6 courses of chemotherapy. Thereafter, she was closely followed up by a gynecologist and a neurologist. Her regular therapy was carbamazepine at a dosage of 800 mg daily.\nThe patient was in remission from July 2011 to October 1, 2012 when she addressed herself to our Institute. A vaginal examination revealed vaginal bleeding and a palpable mass in the lesser pelvis behind the site of the hysterectomy scar. Her physical examination was otherwise normal and, apart from β-hCG units with a tendency to rise, her laboratory analyses were without pathological findings too. An MRI scan of the abdomen and pelvis revealed a tumor of 7.0 × 7.6 × 9.3 cm in size, infiltrating local tissues and indicating a relapse of choriocarcinoma (fig. ). The MRI scan also showed multiple metastases in the right lung. A computed tomography (CT) of the chest showed multiple metastases (fig. ), but the brain CT was normal. Previously, the patient was at FIGO stage IV and had a WHO score of 13, both indicating that she was a high-risk patient with poor prognosis []. Considering the local tumor infiltration of the tissue, surgery was not an option. Instead, she was introduced to 9 courses of EMACO chemotherapy. Her vaginal bleeding persisted and was stopped by vaginal tamponade. Upon therapy, the patient became highly febrile (39°C). Her laboratory findings revealed elevated enzymes because of an acute-phase inflammation [C-reactive protein 361 mg/l, erythrocyte sedimentation rate 150/mm/h (2–10), fibrinogen 10 g/l (2–4), aspartate transaminase 130 IU/l (14–50), alanine aminotransferase 102 IU/l (21–72) and lactate dehydrogenase 546 IU/l (180–360)]. A blood analysis showed pancytopenia [white blood cell count: 3.7 g/l (0–132); red blood cell count: 1.89 ×1012/l (4.10–5.10); hemoglobin 53.5 g/dl (115–165); platelet 125 g/l (150–400)]. The hemostasis tests were within normal ranges. The patient was treated with cephalosporin, ertapenem, metronidazole, ciprofloxacin, neupogen and 4 doses of blood infusion. Three days after the introduction of antibiotics, the patient developed convulsive tonic-clonic seizures, which were partly controlled by carbamazepine. A repeated brain CT did not show metastasis. The patient was transferred to a neurosurgical clinic, where she died from liver failure and infection due to tumor necrosis on the second day after admission.