A 48-year-old woman was admitted to our department with a 6-month history of irregular vaginal bleeding and a 1-month history of a palpable abdominal mass. She had a normal vaginal delivery at 26 years of age and had no recent history of normal pregnancies, molar gestations, or abortions. The physical examination revealed abdominal tenderness and a fixed mass arising from the pelvis to 3 cm below the umbilicus. Ultrasound showed a 15-cm solid mass posterior to the uterus, and consistent with an ovarian tumor. The serum levels of tumor markers, with normal values in parentheses, were as follows: β-human chorionic gonadotropin (hCG), 7,664.3 mIU/mL (<5.0); CA-125, 217.3 U/mL (<35); CA19-9, 18.6 U/mL (<30); alpha fetoprotein (AFP), 1.9 ng/mL (<20); and carcinoembryonic antigen (CEA), 2.5 ng/mL (<5). There was no evidence of metastasis to other organs.
After written informed consent was obtained, an exploratory laparotomy was undertaken for a suspected ovarian tumor. Intra-operatively, a dark-red, soft, friable, 18×15×14 cm mass had replaced the right ovary, which was densely adherent to the colon, rectum, appendix, and posterior surface of the uterus. The left ovary and fallopian tube were normal in appearance. There was no ascites within the peritoneal cavity. Peritoneal washings were obtained for cytology. Cytoreductive surgery, including a sub-extensive total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, para-aortic lymph node sampling, omentectomy, appendectomy, and peritoneal biopsies was performed. Optimal debulking was achieved with no macroscopic residual tumor.
Microscopically, the tumor was confirmed to be a pure choriocarcinoma with widespread necrosis (). The appendiceal serosa and peritoneum were identified with tumor invasion. The uterus, left ovary, left fallopian tube, omentum and all of the extirpated lymph nodes were negative for malignancy. Immunohistochemically, the tumor was positive for β-hCG () and weakly positive for placental-like alkaline phosphatase (PLAP) (). Eighty percent of the tumor cells were strongly positive for Ki-67.
Microscopic appearance of the tumor shows a pure choriocarcinoma with widespread necrosis (H&E, ×200).
Supporting immunohistochemistry shows that the tumor is positive for β-human chorionic gonadotropin (A) and weakly positive for placental-like alkaline phosphatase (B) (×200).
Post-operatively, the patient was treated with bleomycin, etoposide, and cisplatin (BEP) chemotherapy (etoposide [100 mg/m2 on days 1 and 2], cisplatin [20 mg/m2 on days l-5], and bleomycin [30 mg on day 2]) every 28 days. The serum β-hCG level decreased to 193.5 mIU/mL 1 week after surgery and was within the normal range after 3 cycles of chemotherapy (). The patient did well after surgery and tolerated 6 cycles of chemotherapy without problems and without evidence of disease after a 12-month follow-up.
Decrease in serum β-human chorionic gonadotropin (hCG) levels after surgery and combination chemotherapy with etoposide, cisplatin and bleomycin. #number indicates the cycle number of chemotherapy.