The presentation and management of post-partum choriocarcinoma

Abstract

Gestational trophoblastic disease (GTD) is a term that incorporates a rare but important spectrum of disorders that may complicate pregnancy. GTD is most commonly associated with an abnormal conception (either a complete or partial hydatidiform mole or more rarely choriocarcinoma) but it may follow a normal delivery or non-molar abortion. Choriocarcinoma following a live birth is said to have an incidence of 1 in 50 000 births (Bagshawe et al, 1986) and to be associated with a poor prognosis (Bagshaw, 1976;Tidy et al, 1995;Bower et al, 1997). We have evaluated our experience in the management of post-partum choriocarcinoma by undertaking a retrospective analysis of all patients registered and treated for persistent trophoblastic disease (PTD) between 1987 and 1996 at Weston Park Hospital, specifically identifying those patients with post-partum choriocarcinoma. METHODSThe Weston Park Hospital database of gestational trophoblastic tumours was used to identify all women treated for histologically confirmed choriocarcinoma. Patients who presented following full-term non-molar pregnancy had their case notes studied to identify patient demographics, obstetric history, presentation, treatment and outcome.Our current management policy on referral of patients with PTD is to review and confirm the histological diagnosis of choriocarcinoma: the patient undergoes a prognostic risk assessment including full physical examination, imaging [ultrasound pelvis and abdomen, computed tomography (CT) thorax, chest X-ray] and serum β human chorionic gonadotrophin (βhCG) evaluation prior to initiation of treatment as determined by our modified Charing Cross prognostic scoring system (Sheridan et al 1993). Those patients at high risk of central nervous system involvement also undergo a CT scan of the head and a lumbar puncture (provided there is no evidence of increased intra-cranial pressure) to determine the cerebro-spinal fluid:serum βhCG ratio. RESULTSBetween January 1987 and December 1996, 225 women with PTD were treated at Weston Park Hospital. Thirty-one patients received high risk chemotherapy. In nine patients (29%) the antecedent pregnancy was a full-term non-molar pregnancy. In this group, the median age was 29 years (range 22-37), and eight of nine women were multiparous. There was no sexual preponderance in the antecedent pregnancy (four male, five female).The time interval from antecedent pregnancy to onset of symptoms ranged from 0 to 12 weeks (median 2 weeks). All nine patients presented with abnormal vaginal bleeding. In four cases this was persistent from the time of delivery, while in the other five cases the post-partum haemorrhage commenced at a median of 5 weeks after delivery (range 2-12 weeks). Only two women experienced lower abdominal pain.The interval between the antecedent pregnancy and registration for treatment ranged from 5-25 weeks (median 10 weeks). In one case 24 weeks elapsed before referral. The patient underwent three uterine evacuations and only during the final operation was tissue sent for histo...

The Clinical Characteristics and Early Detection of Postpartum Choriocarcinoma

“…3,5,6 However, the prognosis of postpartum choriocarcinoma has greatly improved because of early disease detection and the improvement of treatment protocols. 7,8 Because postpartum choriocarcinoma is a rare entity, limited data are available regarding the clinical characteristics and prognosis of patients with this disease. The aim of this study was to identify the clinical and demographic characteristics and prognosis of patients with postpartum high-risk GTN based on the International Federation of Gynecology and Obstetrics (FIGO) 2000 prognosis scoring system or based on pathologically confirmed choriocarcinoma occurring after term delivery, premature delivery, and stillbirth.…”

A Case of Postpartum Choriocarcinoma: Delay in Diagnosis and Lessons Learnt

“…Dobson et al [4] reported nine cases of postpartum choriocarcinoma and in their series the time interval from antecedent pregnancy to onset of symptoms (vaginal bleeding) was 0-12 weeks. The same authors also reported a patient who was on progestogens for irregular vaginal bleeding postpartum [4].…”

“…Pregnancy and related disorders must be the initial diagnosis in young women with irregular vaginal bleeding as most of the women with vesicular mole (benign form of choriocarcinoma) present with irregular vaginal bleeding and diagnosed as delayed miscarriage or anembryonic pregnancy, as in this patient [2,3]. Dobson et al [4] reported nine cases of postpartum choriocarcinoma and in their series the time interval from antecedent pregnancy to onset of symptoms (vaginal bleeding) was 0-12 weeks. The same authors also reported a patient who was on progestogens for irregular vaginal bleeding postpartum [4].…”

Elevated hCG and a high proportion of hCGβ in serum preceding the diagnosis of trophoblastic disease by seven months

“…hCG in serum is a very reliable marker of trophoblastic tumours 8 and an elevated ratio of hCGb to hCG indicates that the tumour is malignant 3,4 . Because hCG immunoreactivity is quite heterogenous, especially in gestational trophoblastic disease, the choice of an accurate hCG assay is important 9 .…”