Intracerebral hemorrhage as initial presentation of gestational choriocarcinoma: a case report and literature review

Abstract

Choriocarcinoma is the most malignant tumor of gestational trophoblastic neoplasia. It grows rapidly and metastasizes to the lung, liver, and, less frequently, to the brain. One rare case of metastatic cerebral choriocarcinoma with initial presentation of intracerebral hemorrhage is reported. A 40-year-old woman initially presented sudden onset of headache. Intracerebral hemorrhage resulting from ruptured pseudoaneurysm was suspected. Emergent surgery with excision of the pseudoaneurysms was performed. Metastatic choriocarcinoma was accidentally found with positive immunohistochemical staining of cytokeratin and beta subunit of human chorionic gonadotropin (beta-HCG). Choriocarcinoma with brain metastases was diagnosed. She then received chemotherapy with regimen of etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine (EMACO). Elevated serum beta-HCG (30.3 mIU/mL) and new pulmonary lesions were noted by computed tomography 4 months after completion of EMACO. Salvage chemotherapy with etoposide, methotrexate, actinomycin-D, etoposide, and cisplatin (EMAEP) regimen was given. Seven months later after completion of EMAEP, two new pulmonary lesions were detected by positron emission tomography (PET) scan. So she received video-assisted thoracoscopic surgery with tumor excision. Pathologic report confirmed the diagnosis of lung metastases. The patient recovered well. She is free of disease for 12 months. The diagnosis of metastatic cerebral choriocarcinoma was only made by histopathology after craniotomy. Metastatic choriocarcinoma should be always in the differential diagnosis for women at childbearing age presenting with unexplained stroke-like symptoms. In addition, PET scan may be valuable in detecting occult metastatic lesions of choriocarcinoma.

Live Birth following Treatment of Metastatic Cerebral Choriocarcinoma

“…It metastasizes to the lung, vagina, pelvis, liver and less frequently to the brain. 1 In a study of patients having brain metastasis, in cases of gestational choriocarcinoma, pulmonary metastasis was seen in 27 out of 28 cases, 2 but there was no evidence of pulmonany metastasis in our case. This emphasizes that a diagnosis of metastatic cerebral choriocarcinoma should be considered even if pulmonany examination is negative.…”

A Case of Lumbar Metastasis of Choriocarcinoma Masquerading as an Extraosseous Extension of Vertebral Hemangioma

“…Wides- A B pread metastases are characteristic of choriocarcinoam. The favored sites of involvement are the lungs (94% of all metastatic choriocarcinoma), vagina (44%), liver (28%) and brain (28%), followed by the skin, gastrointestinal tract, kidney, breast and bones 11,24) . The clinical signs can be very different, depending on the site of the lesions.…”

“…This tumor is known for its association with molar pregnancy, a rapid hematogenous spread to multiple organs, high HCG levels and a good response to chemotherapy 1,12,17,19,22) . It is preceded by several conditions as follows : 50% arise in molar pregnancies, 25% arise after previous abortions, 23% arise in normal pregnancies and 3% arise subsequent to ectopic pregnancies 11) . Choriocarcinoma has a marked tendency to metastasize early by blood-borne dissemination, like in our case.…”

“…GTDs encompass a heterogeneous group of neoplastic disorders that arise from the trophoblastic epithelium of the placenta and they are characterized by a distinct tumor marker (β-HCG) 1,7,8,11,12,17,20,22,23,25) . GTDs are conventionally classified into at least five distinct groups on the basis of their histopathologic, cytogenetic, and clinical features 12) .…”

“…The most common locations for metastases are the lung and the vulvo-vaginal region, and metastases are less commonly found in the brain and liver. Other sites of metastases, such as the skin, gastrointestinal tract, kidney, breast or bones, are extremely rare 2,4,11,12,15,[20][21][22][23][24] . In this study, we report on a case of metastatic choriocarcinoma that presented with intracerebral hemorrhage and pulmonary hemorrhage and it metastasized to the lumbar spine, and this metastasis to the spine radiologically mimicked an extraosseous extension of vertebral hemangioma.…”