Subcutaneous mass as the primary manifestation of gestational choriocarcinoma: A case report (2011)

1. IntroductionChoriocarcinoma is a highly malignant trophoblastic tumor com-posed of two types of cells, syncytiotrophoblasts and cytotrophoblasts(Seckl et al., 2010). Its incidence is reported variously from 1 in 13,000 to 50,000 pregnancies (Alveyn and Loehry, 1988). Metastasis ismost often associated with choriocarcinomas in contrast to other vari-ants of the GTT (Berkowitz and Goldstein, 1996). Choriocarcinomacommonly metastasizes to the lungs and vagina, and less commonly,to the liver, brain, kidneys and gastrointestinal tract (Bagshawe,1992). Vaginal bleeding, abdominal swelling, amenorrhea, chest andneurologicalsymptomsarethemostcommonpresentationsdependingontheextentofthedisease,butbyfarthecommonestsymptomisvag-inal bleeding, a consequence of the tumor invading the uterus (Chamaet al., 2002).To the best of our knowledge, there was no choriocarcinoma withclinical presentation of subcutaneous metastasis reported in the liter-ature. An abdominal subcutaneous mass as the primary manifestationof choriocarcinoma is extremely rare and difﬁcult for diagnosis. Herewe reported a case of gestational choriocarcinoma with the primarymanifestationof subcutaneousmetastasis10 yearsafterher lastpreg-nancy. No uterine or ovarian tumors were noted except subcutaneoustumor over anterior abdominal wall with bilateral multiple pulmo-nary nodules by image studies. Wide excision of the abdominal tumorrevealed that the tumor cells were positive for cytokeratin and humanchorionic gonadotropin by immunohistochemical stainings. DNA poly-morphism analysis revealed that the tumor cells possessed both geno-mic DNA alleles from the patient and her husband. Gestationalchoriocarcinoma was ﬁnally diagnosed. The serum level of β-hCG inthepatientwas 382 mIu/ml after surgery. So the EMA-COchemothera-peutic regimens (etoposide, methotrexate, and actinomycin, followedbycyclophosphamideandvincristine)weregiven.Thepatientachievedclinicalremissionfor7 monthsafterchemotherapy.Subcutaneousmasscan be the ﬁrst manifestation of choriocarcinoma. Choriocarcinomashould be the differential diagnosis for special manifestation ofwomen in reproductive ages.2. Case reportA49-year-oldwomanpalpatedarapidgrowingmassoverlowerab-domen for three months. Her menstrual cycles became irregular since2 months ago. The patient had conceived 7 times with 4 miscarriagesand her three children were all delivered through cesarean section.Her last cesarean section was 20 years ago and her last pregnancy wasartiﬁcial abortion 10years ago.Pelvicexaminationrevealedasmoothcervix,andnormalsizeofuter-usandbilateraladnexae.Amultilo culatedmasswhichwasaroundbase-ball size within the abdominal wall was noted. The subcutaneous masslocated nearby the wound of the cesarean section with intact abdominalskin. Transabdominal ultrasonography revealed a multilocular tumormeasuring 8×6×5 cm located behind the cesarean scar and within thelower anterior subcutaneous layer. No abnormal ﬁnding was identiﬁedin the endometrial cavity, uterus and bilateral ovaries. Magnetic reso-nance imaging (MRI) study showed a large in ﬁltrative and heteroge-neous mass, measured around 14 cm in largest dimension, and locatedwithin the anterior pelvis wall ( Fig. 1). Computed tomography (CT)study showed bilateral multiple pulmonary nodules. Subcutaneous ma-lignancy with pulmonary metastases was suspected. Biopsies of the ab-dominal wall tumor were undergone and the pathologic reportrevealed a poorly-differentiated squamous cell carcinoma. Immunohis-tochemically, the tumor cells were po sitive for cytokeratin (AE1/AE3)andp63butnegativeforvimentin,CD31,CD34,S-100 protein,calretinin