Cancer Therapy Vol 3, 551-554, 2005
Successful treatment of
gestational trophoblastic neoplasm metastatic to the colon
Fatemeh
Ghaemmaghami*, Farnaz Sohrabvand, Haleh Ayatollahi, Mitra Modarres
Gynecology & Reproductive Medicine, Tehran University
of Medical Sciences
__________________________________________________________________________________
*Correspondence: Fatemeh
Ghaemmaghami, Associate
Professor, Gynecologist Oncologist, Tehran University of Medical Sciences. 2nd
Floor, Department of Gynecology Oncology, Vali-e-Asr Hospital, Keshavarz
Blvd.,Tehran 14194, Iran; Phone: 0098-21-6937766; Fax: 0098-21-6937321; E-mail:
valrec2@yahoo.com, ftghaemmagh@yahoo.com
Key words: choriocarcinoma,
colon metastasis, colostomy, GTN, EMA-EP
Abbreviations:
arteriovenous malformations, (AVM); Federation of Gynecology and Obstetrics
(FIGO); Gestational trophoblastic neoplasm, (GTN)
Summary
Gestational
trophoblastic neoplasm (GTN) normally spreads to the lungs and brain;
metastasis to intra-abdominal organs such as the gastrointestinal tract is
rare. We present a 41-year-old patient with locally invasive GTN who underwent
two urgent laparotomies because of internal hemorrhage. First, a total
hysterectomy was performed to manage perforation of the uterus; one month
later, due to rectal bleeding emergency colon resection with colostomy was
performed because of colon metastasis.
Although the most appropriate management of GTN is chemotherapy,
surgical intervention may be needed due to bleeding that may require resection
of the involved structures.
Gestational trophoblastic neoplasm (GTN) represents a
spectrum of pathologic and clinical alterations, ranging from molar pregnancy
to metastatic gestational trophoblastic neoplasm. Locally invasive GTN develops
in 15% of patients after the evacuation of a molar pregnancy; it infrequently
develops after normal pregnancies, ectopic pregnancies, and spontaneous or
therapeutic abortions. Metastatic
tumors develop after a complete molar pregnancy in 4% of patients, but they are
more common after nonmolar pregnancies (Berkowitz and Goldstein, 1993).
Gestational trophoblastic neoplasm is suspected with
persistent or irregular uterine hemorrhage. Trophoblastic neoplasm may perforate the
myometrium or erode uterine vessels, causing intraperitoneal and vaginal
bleeding, respectively (Berek and Hacker, 2000). Trophoblastic tumors are highly vascular
and prone to severe hemorrhage, either spontaneously or during biopsy. The most
common sites of metastasis are the lungs (80%), vagina (30%), pelvis (20%),
liver (10%), and brain (10%) (Berkowitz and Goldstein, 1996). Less than 5% of
the cases of metastatic GTN involve the intra-abdominal organs (Newlands,
2003). The gastrointestinal tract is a rare site of metastasis; patients with
metastasis to the gastrointestinal tract may present with symptoms of acute
abdomen (Balagopal et al, 2003).
According to various case reports, metastasis to the gastrointestinal
tract may manifest as small bowel perforation, metastasis to the colon may
present as pseudoobstruction (Bandy et al, 1985), and metastasis to the stomach
may present as upper gastrointestinal bleeding (Galloway et al, 2001).
In this report, we describe
a case of GTN metastatic to the colon to demonstrate that surgery may be needed
in the management of gastrointestinal complications.
We present the case of a 41-year-old female patient
gravida 3, para 3, ab 1, post-miscarriage (7 years), and not sexually active.
The patient also had multiple sclerosis and was being treated with
corticosteroids. In September 2002, she was admitted to the general surgery
ward of Vali-e-Asr Hospital with abdominal pain, nausea, vomiting, and
epigastric tenderness. Her hemoglobin value was 9.7g/dl.
Because of an acute abdomen and suspicion of internal
hemorrhage she underwent an emergency laparotomy. Exploration of the abdomen
during laparatomy showed uterine perforation and severe, intractable hemorrhage
(about 1500 ml blood). The patient then underwent a total hysterectomy and
unilateral salpingo-oophorectomy; she had a mass which was similar
to a submucous myoma that was 5cm in diameter.
A histologic examination showed invasive gestational
trophoblastic neoplasm (Figure 1).
The patient was referred to the gynecologic oncology ward for further
management in October 2002. The patientŐs HCG level was 39500 mIU/ml. A
radiologic exam showed multiple sclerosis lesions in the brain, but there was
no evidence of brain metastasis. A chest x-ray revealed multiple lung
metastases.
An ultrasound of the abdomen showed normal abdominal
and pelvic findings. Therefore, according to the International Federation of
Gynecology and Obstetrics (FIGO) 2000 staging/scoring, the patient had stage
III GTN with a total score of 11.
Since the patient was in a high-risk category, a
combined chemotherapy regimen consisting of etoposide, methotrexate,
actinomycin, etoposide, and cisplatin (EMA-EP) was administered. After the
first course of chemotherapy, the patient had a sudden episode of severe rectal
hemorrhage and her hemoglobin level fell to 8g/dl. Therefore, she received a
blood transfusion. A second emergent laparotomy was performed, to explore the
intra-abdominal organs. A lesion was discovered at the splenic flexure of the
colon, ascending to the transverse colon. Because we suspected metastatic
gestational trophoblastic neoplasm to the colon, the lesion was resected and
the patient underwent an emergent colostomy because the bowel was not prepped
for anastomosis. A histologic examination confirmed metastatic GTN to the colon
(Figure 2). Metastasis to the colon
changed the patientŐs GTN to stage IV (distant metastases) with a total score
of 13. The patient received four courses of EMA-EP, followed by weekly HCG
measurements. This was followed by three more courses of chemotherapy, after
which the HCG titer reached normal levels. Another three courses of
chemotherapy were administered, and the colostomy was repaired. At a follow-up
of 30 month, there were no signs of relapse and the patient was well.
We have described a rare case of metastatic GTN with
an unusual presentation and response to treatment. GTN is extremely responsive
to chemotherapy, even in its metastatic forms (Berkowitz and Goldstein, 1996).
Metastases from GTN tend to be highly vascular and have a tendency toward
central necrosis and hemorrhage; therefore, surgical intervention may be
necessary (Newlands, 2003). Indeed, uterine perforation, due to
rapid tumor growth may cause intraperitoneal hemorrhage which would require
immediate surgery (Balagopal et al, 2003). A hysterectomy may be
required in patients with metastatic GTN in order to control uterine hemorrhage
or sepsis. Furthermore, in patients with extensive uterine tumors, a
hysterectomy may substantially reduce the trophoblastic tumor and limit the
need for multiple courses of chemotherapy (Berek and Hacker, 2000).
With the development of advanced interventional
radiology techniques, selective angiographic localization and embolization
techniques have been used to conservatively manage hemorrhage from active sites
of
Figure 1. Choriocarcinoma invading
the myometrium. The right half of the micrograph shows the tumor with a
necrotic area and the left half shows deep myometrium (200X).
Figure 2. Choriocarcinoma with large
bowel metastasis. The tumor (right upper portion of the picture) and large
intestinal mucosa (left lower portion) are seen in a background of extravasated
red blood cells. (400X)
metastatic
GTN and to treat intrauterine arteriovenous malformations (AVM) that can
occasionally develop after the treatment of GTN. Vaginal metastases are most
often treated with selective angiographic embolization after simple packing or
suturing techniques have failed to control hemorrhage (Newlands 2003).
Angiographic abnormalities can persist for many months
after the evacuation of a hydatidiform mole or the treatment of malignant GTN.
However, intractable bleeding from intrauterine AVM after successful treatment
for GTN is a relatively rare complication. Lim et al. studied 14 patients with
selective angiographic embolization over 20 years; hemorrhage was controlled in
11 patients (79%), 6 patients (43%) required a second immobilization for
recurrent bleeding, and only 2 patients (14%) required a hysterectomy (Lim et
al. 2002). Successful full term pregnancies have been reported after this
procedure.
GTN of the gastrointestinal tract can most often be
managed with chemotherapy alone, but some patients will experience bleeding
which would first require resection of the involved structures in order to stop
internal hemorrhage. Liver metastases, while often producing catastrophic
intra-abdominal hemorrhage, are less likely to be successfully controlled with
surgical resection. Selective angiographical embolization techniques should be
considered as an option (Hammond et al, 1980).
High-risk patients and patients with stage IV disease
should be treated with primary combination chemotherapy. We used
EMA-EP regimen as the first-line chemotherapy in this high-risk patient; our
previous studies have shown that this regimen produces acceptable results for
high-risk patients (Ghaemmaghami et al, 2004). Patients generally respond to
three to four cycles of chemotherapy, but we administered three more cycles of
chemotherapy our high-risk patient had a βHCG (Ghaemmaghami et al, 2004;
Matsui et al, 2000).
Alternating EMA-EP chemotherapy with etoposide,
methotrexate, actinomycin, cyclophosphamide, and vincristine (EMA-CO)
chemotherapy is common for high-risk patients.
In conclusion, although combination chemotherapy is
the main treatment regimen used in patients with high-risk GTN, surgical
intervention may occasionally be needed to control hemorrhage.
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