Postgrad Med J: first published as 10.1136/pgmj.64.758.941 on 1 December 1988. Downloaded from Postgraduate Medical Journal (1988) 64, 941-942

Missed Diagnosis

Hepatic metastases due to choriocarcinoma

C.G. Alveyn and C.A. Loehry

Royal Victoria Hospital, Shelley Road, Bournemouth BHI 4JG, UK

Summary: A 34 year old female presented with weight loss and . revealed clinically unsuspected metastatic choriocarcinoma. Severe haemorrhage occurred, and the patient died following complications after laparotomy. The possibility of choriocarcinoma should be remembered in women of child-bearing age who present with liver metastases; biopsy must be avoided until this diagnosis can be excluded.

Introduction

Metastatic is most commonly due to examination was otherwise unremarkable. Investi- Protected by copyright. adenocarcinoma, and liver biopsy is frequently gation showed: haemoglobin 73g/l, mean red cell undertaken to provide histological confirmation of volume 84 fl, white cell count 8.3 x l09/l, platelet the diagnosis. We report an unusual case in which count 206 x 109/l, prothrombin ratio 1.5, kaolin hepatic metastases were due to choriocarcinoma. cephalin clotting time 45 seconds (control 40 seconds). showed: 17 Mmol/l, 288 IU/l (normal Case report range 20-90), aspartate aminotransferase 33 1U/l (normal range < 18), lactate dehydrogenase 376 IU/l A 34 year old woman presented with a 4-week (30-90), total protein 63 g/l, and albumin 32 g/l. history of anorexia, nausea, abdominal discomfort Hepatitis B surface antigen was not detected. The and weight loss of 5kg. For 2 weeks she had had serum alpha fetoprotein concentration was less than an intermittent , and 2 days prior to admission 5kU/l (normal range <10). The chest radiograph she developed right hypochondrial pain. was normal. Abdominal ultrasound examination

Eighteen months previously she had experienced revealed a grossly enlarged liver with multiple http://pmj.bmj.com/ transient neurological symptoms, possibly due to hyperechoic areas throughout both lobes, strongly brain stem demyelination, which resolved comple- suggestive of metastases. tely. She was married, with two children aged 5 The patient was transfused with 5 units of blood, years and 23 months; both were full term normal after which her haemoglobin rose to 110 g/l and her pregnancies. An intra-uterine contraceptive device prothrombin ratio improved to 1.2. Percutaneous was inserted after the birth of her second child. liver biopsy was then undertaken to obtain histo- This was removed five months before admission logical confirmation of the suspected diagnosis of because of irregular periods and intermenstrual metastatic liver disease. Approximately 18 hours on September 23, 2021 by guest. bleeding. later the patient began passing large amounts of On examination, she was pale and ill-looking, but altered blood per , with a fall in blood anicteric. In the abdomen a firm tender liver was pressure to 90/50 mmHg. A rapid blood transfusion palpable 10cm below the costal margin. Rectal and was commenced. Upper gastrointestinal endoscopy vaginal examination was normal, and physical was normal to the second part of the duodenum. revealed fresh blood appearing from Correspondence and present address: C.G. Alveyn, M.B., the terminal ileum, but no colonic lesion. Coeliac M.R.C.P.(UK), Department of Medicine II, South axis and mesenteric angiography failed to demon- Laboratory and Pathology Block, Southampton General strate the source of blood loss. The patient con- Hospital, Tremona Road, Southampton S09 4XY, UK. tinued to bleed briskly, and she was therefore Accepted: 11 August 1988 referred for laparotomy. ©) The Fellowship of Postgraduate Medicine, 1988 Postgrad Med J: first published as 10.1136/pgmj.64.758.941 on 1 December 1988. Downloaded from 942 C.G. ALVEYN AND C.A. LOEHRY

At operation, the liver was found to be largely months, and only two cases out of 30 (6.7%) replaced by numerous friable tumour deposits. One presented after 20 months post-delivery.1 of these, in the right lateral aspect of the liver, had A high proportion of patients with choriocarci- ruptured and was bleeding profusely. This was noma have metastases at presentation, the com- 'shelled out' and sent for histological examination. monest sites involved being the lungs, vagina and There was considerable difficulty in securing hae- central nervous system. Liver metastases are less mostasis, which was only achieved after ligation of common, occurring in 4 - 20% of patients with what was believed to be the common hepatic artery. metastatic trophoblastic disease.' 3 The liver may Subsequently her progress was poor, with a be the sole site of spread, and in one series 5 out of steadily rising bilirubin. Histology of the operative 15 patients with hepatic involvement had no other specimen revealed necrotic liver and isolated clus- detectable site of metastases.3 Distant spread of ters of large tumour cells consistent with chorio- choriocarcinoma in the absence of a uterine tumour carcinoma, which stained positively for human is well documented.4'5 This might be explained by chorionic gonadotrophin (HCG) by immunoperoxi- regression of the primary tumour after it has dase. The serum HCG concentration was greatly metastasized; by the occurrence of malignant elevated at 280,0001U/l. change in blood-borne trophoblast; or by depor- Treatment was commenced with actinomycin D, tation of all the trophoblast which has undergone and the patient was transferred to a specialist unit. malignant change.1 In view of her deepening , a further liver The case described above is somewhat unusual in ultrasound scan was performed, which showed its combination of features: the liver was the only marked dilatation of the biliary tree. A second lap- site of : no primary tumour was found; arotomy was undertaken, which revealed a ligature and there was a long latent period between the around the common hepatic duct. This was antecedent (normal) pregnancy and presentation. removed, but severe haemorrhage occurred from The clinical picture led to an initial diagnosis ofProtected by copyright. the friable tumour deposits in the liver. Haemo- metastatic adenocarcinoma from an occult gastroin- stasis could not be achieved, and the patient died testinal primary tumour, with multicentric hepato- intra-operatively. Necropsy confirmed the presence cellular carcinoma a less likely possibility. of choriocarcinoma throughout the liver. However, Liver biopsy was undertaken in an attempt to there was no evidence of tumour in the uterus or in obtain a histological diagnosis. This led to rupture any other organ. of one of the friable hepatic metastases, with massive haemobilia presenting as rectal bleeding. The severe haemorrhage and surgical complications resulted in a fatal outcome. Discussion The possibility of choriocarcinoma should be remembered in women of child-bearing age who Choriocarcinoma is a rare malignant tumour of present with hepatic metastases from an occult trophoblast, complicating between 1: 13,000 and tumour. In view of the recognized danger of haemor-

1:50,000 pregnancies in Caucasian populations. The rhage, liver biopsy should be deferred until serum http://pmj.bmj.com/ incidence is much higher in Asia. In Bagshawe's HCG or 24-hour urinary HCG excretion has been series, 66% of cases occurred after molar pregnan- measured. If an elevated HCG value is found in the cies, with smaller proportions following abortion absence of pregnancy, biopsy must be avoided. The (15.2%) and term delivery (18.8%). The mean time patient should be referred to a specialist centre for to presentation after term delivery was 11.2 further assessment and treatment.

References on September 23, 2021 by guest. 1. Bagshawe, K.D. Choriocarcinoma: the Clinical Biology 4. Freeth, D. & McCall, A.J. Chorioepithelioma with of the Trophoblast and its Tumours. Edward Arnold, amenorrhea: massive hepatomegaly with undiscovered London, 1969. primary tumour. J Obstet Gynaec Brit Emp 1950, 57: 2. Gordon, A.N., Gershenson, D.M., Copeland, L.J., 757-764. Saul, P.B., Kavanagh, J.J. & Edwards, C.L. High-risk 5. Seedat, Y.K. & Immerman, I. Unusual clinical presen- metastatic gestational trophoblastic disease. Obstet tations of chorionepithelioma. S Aft Med J 1965, 39: Gynecol 1985, 65: 550-556. 75 1-752. 3. Wong, L.C., Choo, Y.C. & Ma, H.K. Hepatic metas- tases in gestational trophoblastic disease. Obstet Gyne- col 1986, 67: 107-111.