Intraplacental Choriocarcinoma: Rare or Underdiagnosed? Report of 2 Cases Diagnosed after an Incomplete Miscarriage and a Preterm Spontaneous Vaginal Delivery

Abstract

Intraplacental choriocarcinoma is a rare malignant tumor diagnosed after an abortion, an ectopic pregnancy, or a term or preterm pregnancy or following the diagnosis of a hydatidiform mole. During pregnancy, it may be more common than reported, as most patients are asymptomatic and placental choriocarcinomas are usually inconspicuous macroscopically and are often mistaken for an infarct. Based upon a case study methodology, we describe 2 cases of intraplacental choriocarcinoma: the first case was identified in the product of a uterine curettage following an incomplete miscarriage and the second in one of the placentas of a bichorionic twin pregnancy. Maternal investigation did not reveal evidence of metastatic disease and neither did the infants' one in the second case. The two cases underwent maternal surveillance with serum hCG and remained disease-free until the present. In conclusion, intraplacental choriocarcinoma is easily underdiagnosed but with current treatment, even in the presence of metastasis, the prognosis is excellent. A routine microscopic examination of all the placentas and products of miscarriage can increase the real incidence of this entity and consequently improve its management.

Is chemotherapy always necessary for patients with nonmetastatic gestational trophoblastic neoplasia with histopathological diagnosis of choriocarcinoma?

“…With expectant management, we were able to avoid chemotherapy exposure to over half of our patients without the development of more advanced disease, greater need of multi-agent chemotherapy or in any case of death or relapse. While withholding immediate chemotherapy from women with a histologic diagnosis of choriocarcinoma may contravene current FIGO guidelines [9], our observation of the safety of this approach is similar to other reports [12][13][14][15][16][17][18][19][20]. Pathological diagnosis of GCC in specimens from uterine evacuations following molar pregnancies or abortions, salpingectomies in suspected ectopic pregnancies, or even placentas of preterm or term deliveries are not promptly available for Brazilian patients and physicians in the public health systemtaking generally 6-7 weeks for the final pathological results.…”

“…The choice to treat these patients could be viewed as an over-treatment, since they do not show signs of active disease. Several small reports describing expectant management of patients with close clinical and hCG surveillance suggest that women with surgically evacuated choriocarcinoma may enter remission without receiving chemotherapy [12][13][14][15][16][17][18][19][20].…”

First-trimester miscarriage: A histopathological classification proposal

“…Also, extravillous trophoblastic lesions are a complex and heterogeneous group of lesions, since benign non neoplastic lesions (e.g., placental site nodule and exaggerated placental site) to potentially malignant conditions such as placental site trophoblastic tumor and intraplacental choriocarcinoma. Histology of all the products of early miscarriage can increase the real incidence of gestational trophoblastic disease and consequently improve maternal management [ 32 , 33 , 34 , 35 , 36 , 37 , 40 , 41 , 42 ].…”

“…Placental site nodule is a benign, well circumscribed nodule consisting of trophoblastic cell proliferation. Choriocarcinoma is a malignant trophoblastic tumor consisting of a trimorphic proliferation of extravillous trophoblastic cells, syncytiotrophoblast and cytotrophoblast, in the absence of chorionic villi [ 31 , 37 , 39 , 40 ]. Placental site trophoblastic tumor is a trophoblastic neoplasia consisting of neoplastic implantation site-type extravillous trophoblast, while the epithelioid trophoblastic tumor consist of neoplastic chorionic-type extravillous trophoblast [ 31 , 37 , 39 , 40 , 41 ].…”

A Case of Intraplacental Choriocarcinoma with Pulmonary Metastasis

“…Intraplacental choriocarcinoma is generally diagnosed during the postpartum examination of the placenta, or during evaluation based on disease-related symptoms. As examination of the placenta is not performed routinely, a lack of symptoms can make it difficult to detect intraplacental choriocarcinoma [1, 2]. Previous reports suggest that intraplacental choriocarcinoma cases amount to approximately 2% of gestational choriocarcinomas [2, 3].…”