Cancer Therapy Vol 2, 549-552, 2004

 

Pregnancy post choriocarcinoma treatment

Case Report

 

Branka Nikolic

Obst. Gyneacol. Clinic "Narodni front", School of Medicine, University of Belgrade; Narodnog fronta 62, 11000 Beograd, Serbia and Montenegro

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*Correspondence: Branka Nikolic, MD, PhD, University Teaching Clinic of Gynecology and Obstetrics "Narodni front", Narodnog fronta 62, 11000 Beograd, Serbia and Montenegro; Tel: +381 11 36 05 345; Fax: +381 11 36 10 863; e-mail: n_branka@eunet.yu

Key words: Gestational trophoblastic neoplasm, choriocarcinoma, chemiotherapy, transvaginal Doppler ultrasonography,resistance index

Abbreviations: b choriogonadotropine, (b hCG); Gestational Trophoblastic Neoplasm, (GTN); esistance Index, (RI)

Received: 8 December 2004; Revised: 19 January 2005

Accepted: 26 January 2005; electronically published: January 2005

 

Summary

This is a case report of pregnancy 4 months after polychemiotherapy treatment of malignant GTN- Choriocarcinoma. Cesarean section was done at 39ed week gestation. Gestational Trophoblastic Neoplasm (GTN) is rare event usualy appearing in women younger than 20 and older than 40. Malignant types of GTN such are Invasive mole, Placental syte trophoblastic tumor and Choriocarcinoma can cause a serious damage of uterine tissue structure which could have an impact on future reproductive function. Even in those cases with malignant GTN and polychemiotherapy treatment reproductive health could be preserved. Diagnosis of malignant GTN depends of clinical findings, blood b choriogonadotropine (b hCG) level, hystological and ultrasonographic findings. It is not easy to diagnose malignant GTN. Uterine bleeding, nausea, vomiting, painful breasts, increasing blood b hCG, unusual US finding in uterine structure, ovarian theca luteal cysts and finaly hystological assesment are important in making the final diagnosis of malignant GTN reliable (Disala and William, 1997). Ultrasound is helpful but of a limited value in detecting malignant GTN because of almost normal US findings in majority of cases. In some cases uterine tissue damage in malignant GTN could be so large to make those changes possible for transvaginal Doppler ultrasonography detection and to followe up them during and after the treatment. US findings mean detection of trophoblastic tissue protrudion in uterine wall different in echogenicity than normal uterine tissue, or foci of destruction seen as anechoic spaces in uterine tissue (Kurjak, 1994; Tepper et al, 1994; Yalcin et al, 2002; Nikolic and Lukic, 2004). Both changes are usualy followed with Resistance Index (RI) value lower than 0,5 (Kurjak, 1994; Tepper et al, 1994; Nikolic and Lukic, 2004). This lower RI is expected to find in a field of neovascularisation surrounding malignant tissue where those vessels do not have muscle tissue in their walls (Kurjak, 1994; Nikolic and Lukic, 2004). Ovary theca luteal cysts are not always present in malignant GTNs. Inspite of a degree of malignant potential that choriocarcinoma could develop this case is an example of early reversible reproductive function after choriocarcinoma treated by mean of polichemotherapy (EMA) and single agent chemotherapy (Methotrexate) in repeated treatment.

I. Case Report

A 19 year old patient, nullipara, came to our hospital because of uterine bleeding, nausea and painful breasts two weeks after GTN-complete mole diagnosed and vacuum aspiration done.

Patient was hospitalised because of increasing blood b hCG (from 7800 - 18090 IU/l) and US findings suggestive of GTN with theca luteal cysts on both ovaries (Figure 1).

Vacuum aspiration was done at 7th weeks gestation because of complete mole. Blood b hCG decreases from 87 000 IU/l to 7800 IU/l ten days after vacuum aspiration and complete mole was hystologicaly confirmed. The first US picture was caracteristic for complete mole without ovaries theca luteal cysts.

Two weeks after vacuum aspiration specific changes in uterine structure were seen during transvaginal Doppler US. There were two anechogenic foci (Figure 2) in anterior uterine wall close to uterine cavity suspected on malignant trophoblastic tissue destruction with hot spots. There was not residual tissue in uterine cavity. Resistance Index values on vessels surrounding those changes in uterine wall were lower than 0,5. Theca luteal cysts were seen on both ovaries.

According to FIGO 2000 staging and scooring system this GTN was Stage I and Score 3.

Radiography of lungs and brain was done and no metastases detected.

Curettage performed and choriocarcinoma confirmed. Methotrexate (50mg) was administrated before curettage.

After hystological assesment chemotherapy treatment proceeded with EMA (Etoposide, Methotrexate, Actynomycin-D). Because of significant clinical response to EMA (hematological toxicity with neutropenia and platelet count less than 90 during treatment the second treatment was proceeded with the single chemotherapy. Methotrexate was administrated during the second treatment.

Treatment of malignant GTN must be continued with repeated courses of chemotherapy when necessary and blood b hCG has to be measured until titers return to nondetectable level.

Anaechogenic foci in uterine wall were measured before the treatment and they were from 0,9-1,1 cm in diameter with Resistance Index values on a vessel in surrounding uterine tissue 0,436-460.

Figure 1. Ovary theca luteal cysts

Figure 2. Two malignant foci of destruction in anterior uterine wall (like a picture of twin pregnancy above uterine cavity) .

b hCG values have decreasing rate after second treatment by mean of Methotrexate. The last value of b hCG was 121 IU/l.

Patient left hospital and interrupt the Follow up programm on her own risk without checking blood b hCG . Five months after treatment she came because of poor menstrual bleeding. US done and theca luteal cysts on both ovaries seen during the previous hospitalisation were unchanged (Figure 2).

No viable intrauterine or ectopic pregnancy was seen during US examination. Foci of destruction that choriocarcinoma left in uterine wall were compared with previous findings. No signigicant changes in US findings were found. Blood b hCG evaluation recommended but patient did not do it.

She came again to our hospital in 39ed week gestation when delivery started. Cesarean section was done because of breech presentation.

There were no viable changes on uterine structure during the operation. Enlargement of both ovaries was caracteristic with multiple cysts. Ultrasonograpy was done seven days after Cesarean section and two foci of destruction in uterine wal detected before choriocarcinoma treatment were not seen. Theca luteal cysts seen in the moment of delivery stayed unchange during next 9 months when started reversing to normal in another 4 months.

Patient was clinicaly, laboratory( b hCG), hystologicaly (placenta and cord) and ultrasonographicaly examined and left hospital in good condition as a healthy person with healthy baby.

II. Discussion

Early diagnosis of malignant GTN and treatment according to accepted protocols could preserve reproductive health in patients with malignant GTN. Duration of reproductive health recovering is varying in this group of patient.

During last five years ( 1999-2004) we treated 54 GTN cases and 14 of them were malignant GTN with polychemiotherapy treatment . Four of them were pregnant after 4 , 25, 26 and 43 months after the treatment.

During five year period before 1999( in 1999 unpowerishment uranium was used during war in Former Yugoslavia) only 21 GTN cases were treated on our department and 2 of them were malignant GTN.

We will present complete GTN data for the whole country in next years.

Malignant GTN has to be clinicaly, ultrasonograpficaly, laboratory and histologycaly confirmed and treated without delay. Blood b hCG is of a great value for early diagnosis as well as in checking the effects of treatment. Transvaginal Doppler ultrasonographic findings are not always in correlation with b hCG levels at the begining of diagnostic procedure and during various stages of treatment (Kurjak, 1994; Tepper et al, 1994; Nikolic and Lukic, 2004). It is of a limited value in malignant GTN because in the great number of malignant GTNs ultrasonographic findings are not more specific than normal ultrasonographic finding.

Transvaginal Doppler ultrasonography is noninvasive and could be useful diagnostic approach in detecting specific cases of malignant GTNs with unusual findings in uterine structure (Figure 2).

Another problem in detecting malignant GTN is that it is not always possible to confirm it histologicaly after the curettage because of deep protrudion of malignant trophoblastic tissue in uterine wall.

Increasing blood b hCG with US findings of malignant foci of trophoblastic tissue protrudion in uterine walls, tissue destruction, hot spots (hypervascularisation), low Resistance index lower than 0,5 and ovary theca luteal cysts can be helpful in making decision for starting with chemotherapy in such cases.

Blood b hCG has to be measured in all GTN cases especialy when there is an increasing rate. Serious examination of GTN includes hystological confirmation and treatment has to be proceeded early as possible.

Followe up programme has to be respected until three sequential blood b hCG show negative values.

Recovery of reproductive function is possible even in malignant GTN cases with foci of uterine tissue destruction after polychemiotherapy treatment .

Acknowledgements

This work is a part of project No 1-333 Supported by Ministry of Health and Welfare, Serbia and Montenegro.

References

Nikolic B, Lukic R (2004) Choriocarcinoma-postdisease ultrasonographic findings; Int J Gynecol Cancer 14,677-679

Yalcin OT, Oyalp SS, Tanir HM (2002) Assesment of gestational trophoblastic disease by Doppler ultrasonography. Eur J Obstet Gynecol Reprod Biol 103, 83-7

Disala PJ, William TC (1997) Clinical Gynecologic Oncology: Fifth edition, Boston; 180-199.

Kurjak A (1994) An Atlas of transvaginal color Doppler The current state of the art: The Parthenon Publishing Group

Tepper R, Shulman A, Altaras M, Goldberger S, Maymon R (1994) The role of color Doppler flow in the management of nonmetastatic gestational trophoblastic disease. Gynecol Obstet Invest 38, 14-17.

 

 

Branka Nikolic