CHORIOCARCINOMA

 Choriocarcinoma is a rarely occurring,

highly malignant tumour that arises from the
trophoblastic epithelium.
 It is characterized by producing enormous
amounts of β-hCG, by its early blood borne
metastases to the lungs, liver and brain, and
by being extremely sensitive to
chemotherapeutic agents.
Classification of Gestational
Trophoblastic Disease (GTD):

Benign Malignant
Hydatidiform Mole Choriocarcinoma
A) Complete Mole A) Non metastatic
B) Partial Mole B) Metastatic

- Low risk

- High risk
INCIDENCE:

 Itoccurs in about 1/50000 pregnancies, and

is nearly 10 times higher in the far-east
countries than in other regions in the world.
 About 50% of choriocarcinomas follow a
molar pregnancy, 30% occur after abortion
and 20% follow a normal pregnancy. It may
rarely occur after ectopic pregnancies.
Low-risk and high-risk cases are
classified according to several factors

 Age of patient and type of antecedent pregnancy

(mole, abortion or term pregnancy).
 Duration between antecedent pregnancy and
diagnosis of choriocarcinoma.
 Level of serum β-hCG, and tumour size.
 Site and number of metastatic lesions, and previous
response to chemotherapy treatment.
GROSS PATHOLOGY

 Multiple haemorrhagic nodules of variable

size invading the myometrium.
 Central necrosis, surrounded by a rim of
viable tumour disrupting the muscle fibres
and invading maternal vessels.
 Genital and extragenital haematogenous
spread occurs in about 50% of cases.
MICROSCOPIC PATHOLOGY

 Central core of mononuclear cytotrophoblast

surrounded by a rim of multinucleated
syncytiotrophoblast.
 Distinct characteristic absence of chorionic
villi.
 Extensive areas of necrosis and
haemorrhage.
SPREAD OF CHORIOCARCINOMA

 A) Haematogenous spread:
choriocarcinoma is famous for its early and
widespread blood borne metastases to
various sites including;
 Pulmonary metastases (up to 80% of cases)
 Vaginal metastases (30%)
 Hepatic metastases (10%)
 CNS, especially brain metastases (10%)
 B) Direct spread: Direct myometrial invasion
is not uncommon.
CLINICAL PRESENTATION

 Persistent abnormal symptoms and signs after

pregnancy termination, molar evacuation, abortion
Symptoms and signs include;
 Persistent vaginal bleeding,
 enlarged or subinvoluted uterus,
 persistent theca lutein cysts of the ovaries.
 Pain after molar evacuation, is a rare presentation.
DIAGNOSIS OF CHORIOCARCINOMA

 Abnormally elevated serum β-hCG levels on diagnosis of a

molar pregnancy.
 Abnormal postmolar- regression curve (PMRC) i.e.
persistent, high β-hCG levels after molar evacuation, or
pregnancy termination, with failure to decline gradually in the
first few weeks.
 Empty uterus by ultrasonography (no residual molar
contents).
 Dilatation and curettage (D&C) operation may help in
diagnosing those cases in which the tumour is still present
within the endometrial cavity or cases with myometrial
invasion.
Metastatic work-up includes

 Pelvic TVS & TAS, to evaluate uterus (residual

contents) and adnexae (theca lutein cysts).
 Chest X ray, to detect lung metastases.
 Abdominal US, to detect liver metastases.
 C.T. scan, to diagnose liver, lung and brain
metastases.
 MRI may detect myometrial invasion (Invasive
mole).
TREATMENT OF CHORIOCARCINOMA

 Chemotherapy is the preferred and most effective

line of treatment in the vast majority of the cases as
the tumour is generally chemosensitive.
Chemotherapy also has the benefit of treating distant
metastases effectively.
 Single agent chemotherapy: (methotrexate) for
non-metastatic and low- risk cases.
 Combination chemotherapy is indicated in
metastatic high- risk cases.
 Surgery: in the form of TAH-BSO has a
limited role in choriocarcinoma. It may be
indicated in the multiparous elderly patient,
with other possible complications as severe
intractable bleeding, pyometra, perforation,
or associated uterine or ovarian pathology
 Complete remission: Defined as an hCG
titre that remains negative for three
consecutive weeks even in the presence of
non-viable metastases.
 Cure is considered if the patient is disease-
free for five years.