Sex: female
Age: 31 years
History
Salpingectomia one month ago because of a ruptured ectopic pregnancy. The histology showed abortion tissue. No menstruation after the operation. Diffuse abdominal pain for 4 days. Nausea and breast-tension.
Laboratory data
Not available.
Physical findings
Blood pressure 70/40. Peritoneal affection. Emergency ultrasonography showed
intraperitoneal fluid and a multicystic mass in the corner of the uterus corresponding well with the earlier salpingectomy.
At emergency laparotomy the uterus was found pregnant and the uterine corner dilated and
bluish discoloured. The uterine corner was resected and haemostasis obtained, following an
intraoperative bleeding of 2 litres.
Case text
The patient was admitted as an emergency due to intense abdominal pain and pain in the back and shoulders.
Image 1-2
X-ray examinations of the chest.
Supine chest radiography one day after the operation (image 1). Erect chest radiography 2 days after the examination (image 2).
Image 3-5
Ultrasonography of the pelvis.
Transabdominal sagittal view of the uterus (image 3).
Transvaginal ultrasonogram (image 4).
Colour Doppler ultrasonogram (image 5).
Image 6-10
CT of the abdomen.
Axial post-contrast CT-examination. 10 mm slice thickness, at different levels in the pelvis (images 6-10).
Image 11-13
MRI of the pelvis.
Axial T2-weighted image (TR/TE 3900/102) (image 11).
Sagittal T1-weighted image (TR/TE 580/16) (image 12).
Sagittal STIR image (image 13).
Image 14-18
CT of the pelvis 4 months after the diagnosis. The HCG has normalized.
Axial, post-contrast CT, 10 mm slice-thickness, at different levels in the pelvis (images 14-18).
Image 1-2
1. What are the abnormalities present on the chest films?
Multiple confluent pulmonary opacities and some more sharply defined rounded areas of consolidation. Pleural fluid, especially on the right side, is seen on the first chest X-ray. On the second, the confluent pulmonary opacities and the pleural fluid have disappeared, but
more sharply defined rounded areas of consolidation appeared.
2. What is your diagnosis?
Persistent trophoblastic disease with lung manifestations.
3. What is the differential diagnosis?
A new ectopic pregnancy combined with multi focal pneumonia, pulmonary oedema, allergic infiltrations, or ARDS.
4. What laboratory data is needed, and what is your next diagnostic step?
HCG.
Imaging of the abdomen, pelvis, and brain.
Image 3-5
5. What are the abnormalities seen on the ultrasonograms?
Enlarged uterus. Hypervascular high echogenic tumor between the bladder and the uterus with invasion of the bladder. Similar changes can be seen in the vagina from the distal part, and can be followed proximally, around the urethra to the cervix area.
Image 6-10
6. What are the abnormalities present on the CT scan?
A large vascular tumor involving the uterus, cervix, and vagina. The tumor cannot beseparated from the bladder, the rectum, the iliacal vessels, and the musculature by fat planes. Invasion of the bladder wall is obvious.
Image 11-13
7. What are the abnormalities present on the MR scan?
On the T1-weighted mage low-signal intensity and on the T2-weighted image high-signal intensity areas represent vessels. The vascular tumor cannot be separated from the bladder, but from the rectum. On the STIR sequence the low-signal intensity areas represent vessels with a high flow. The tumor can be followed to the cervix area and vagina.
8. What is the next step?
Follow-up HCG and follow-up imaging. After the HCG has normalized due to chemotherapy, scans have to be performed to rule out a residual-tumor, which needs surgery.
Image 14-18
9. Comment on the evolutive aspects of the images compared to set C.
The tumor has regressed in size. The tumor is still vascular and involves the bladder.
Final diagnosis
Choriocarcinoma with metastases to the lung and invasion of the vagina and pelvic structures.
Differential diagnosis
None.
Discussion
Choriocarcinoma may arise from malignant transformation following a molar pregnancy, or may follow an abortion, a normal pregnancy, or an ectopic pregnancy. Rarely a long latent period before presentation can be seen.
Choriocarcinoma arises from villous trophoblasts, but unlike the invasive moles, chorionic villie are absent.
The tumor forms a hemorrhagic mass within the uterine cavity. Large tumors may penetrate and destroy the uterine myometrium. Primary surgery has only a limited role, as chemotherapy is curative in most patients. Nevertheless hysterectomy may present the only cause of action for the management of uncontrolled uterine hemorrhage or uterine rupture.
However, local excision of involved myometrium can be successfully undertaken to make further fertility possible. Metastatic disease, when present, involves the lung in more than 90% of the cases. Varying degrees of local invasion can be seen, and metastases to the liver and brain are not rare.
Once the diagnosis has been established, follow-up is critical. The corner-stone is frequent measurement of HCG. Ultrasonography, CT, or MRI are convenient for monitoring the progress of the disease, although they do not reach the sensibility of measurements of HCG, and should not be used as a substitute. Large residual tumors may persist after the normalization of HCG, but often disappear without supplementary surgery.
Trophoblastic cells are normally invasive, and even in normal pregnancies they can be found invading the myometrium and even blood vessels. Some trophoblastic cells may be carried to the lungs, but they always regress and disappear. This event may cause confusion in diagnoses, being mistaken for malignant invasion.