new treatment modalities in choriocarcinoma explained in a very simple and lucid manner.

1. CHORIOCARCINOMA
DIAGNOSIS AND MANAGEMENT
DR.ATHUL ABHILASH
SMIMS

2. Gestational choriocarcinoma
 A malignant neoplasm composed of large sheets of
biphasic, markedly atypical trophoblast without
chorionic villi

3.  Gestational choriocarcinoma may occur subsequent to
a molar pregnancy (50% of instances), an abortion
(25%), a normal gestation (22.5%) or an ectopic
pregnancy (2.5%)
 In rare cases an intraplacental choriocarcinoma is
diagnosed immediately following pregnancy from
placental pathological examination

4. Morphology
 The choriocarcinoma is classically a
soft, fleshy, yellow-white tumour with a
marked tendency to form large pale
areas of ischemic necrosis, foci of
cystic softening, and extensive
haemorrhage

5. Histopathology
 The classic pattern of choriocarcinoma has been described as
bilaminar, dimorphic, or biphasic.
 Alternating arrangement of mononucleate trophoblastic cells and
syncytiotrophoblastic cells characterizes choriocarcinoma.
 The intermediate trophoblast in choriocarcinoma may show
marked variation in the degree of cytologic atypia.

6.  Vascular invasion often is prominent.
 Chorionic villi are not a component of choriocarcinoma that
differentiates choriocarcinoma from invasive mole.
 Choriocarcinoma lacks the intrinsic endothelium-lined vascular
channels in the centre of a tumour, making it a unique malignant
solid tumour.

8. Tumour spread and staging
1. DIRECT SPREAD : to the parametrium, tubes and ovaries.
2. BLOOD SPREAD : occurs early to distant organs. The commonest
sites are
 1-Lungs(80 %)
 2-Vagina(30 %)
 3-Brain(10 %) and
 4-Liver(10 %).

9. FIGO classification
 Stage I Disease confined to uterus.
 Stage II Extends outside of the uterus but is limited to the genital
structures (adnexa ,vagina , broad ligament).
 Stage III Extends to the lungs, with or without known genital tract
involvement.
 Stage IV metastases to other organs ( brain, liver , kidneys,
ovaries, bowel)

11. CLINICAL FEATURES
 1- Persistent or irregular vaginal bleeding: it is the commonest
symptom occurring after labour, abortion or evacuation of a vesicular
mole. Bleeding can occur within days or months but rarely after 2
years.
 2- Vaginal discharge: which is blood stained and offensive due to
ulceration and infection of the growth .
 3- amenorrhea: may be present due to continuous hCG production.
 4-Dyspnoea and haemoptysis are noticed with lung metastasis.
 5-The appearance of neurological symptoms like hemiplegia,
epilepsy, headache and visual disturbances suggest brain metastasis.

12. MANAGEMENT
 INVESTIGATIONS
 (1) Uterine curettage: should be done in every case of persistent or
irregular uterine bleeding after labour, abortion or molar pregnancy.
However, intramural tumour cannot be detected by curettage.
 (2) Serum β-hCG: persistent or rising titres in absence of pregnancy are
indicative of trophoblastic neoplasia.(if the level rises more than 100,000
mIU/ml, it is a risk factor)

13.  (4) IMAGING: Regardless of the imaging modality used,
choriocarcinoma often appears as a mass enlarging the uterus.
Sometimes it manifests as a discrete, central, infiltrative mass. Its
heterogeneous appearance correlates with necrosis and haemorrhage
that characterise these lesions.
 Plain X-ray chest: may show secondaries in the form of " cannon balls" or
"snowstorm" appearance

15.  Ultrasonography: to detect tumour, cystic ovaries and exclude
remnants of conception.
 CT scan: for lungs, liver, brain and bone.

16.  Lumbar puncture: to rule out meningitis and also to measure the
hCG level in the CSF.
 Blood studies:
 a- complete blood picture including platelet count.
 b- Renal, liver and thyroid function tests.
 c- Blood group.

17. Treatment:
 Chemotherapy is the treatment of choice for choriocarcinoma.
 METHOTREXATE is the drug of choice.(this drug interferes with the
formation of nucleic acid and mitosis in the malignant cells and
thereby arrests the growth).
 In low risk patients-single drug i.e.methotrexate is given.
 If the patient has jaundice then actinomycin D should be given.

18. SINGLE DRUG REGIMEN IN LOW RISK
CASES

19. MULTIDRUG THERAPY
 Multidrug therapy used most commonly is Bagshaw regime consisting of:-
 E=ETOPOSIDE (100 mg/m2 IV infusion in saline over 30 min).
 M=METHOTREXATE (100mg/m2 IV infusion over 12 hours)
 A=ACTINOMYCIN D(0.5 mg IV stat)
 C=CYCLOPHOSPHAMIDE (600 mg IV in saline)
 O=VINCRISTINE(ONCOVIN) (10 mg/IV stat)
 High risk patients and patients with stage 4 are to be treated with
combination chemotherapy-EMACO.
 This course is repeated every 3 weeks.

20. ROLE OF SURGERY
 1. TOTAL HYSTERECTOMY is done if required in choriocarcinoma.The
ovaries are not usually involved and if involved, can be effectively
cured with postoperative chemotherapy, hence bilateral
salpingoopherectomy is not done.

21. INDICATIONS OF HYSTERECTOMY
 Lesions confined to the uterus in women aged ›35 years, not
desirous of fertility.
 Placental site trophoblastic tumour.
 Intractable vaginal bleeding.
 Localized uterine lesion resistant to chemotherapy.
 Accidental uterine perforation during uterine curettage.

22.  2. LUNG RESECTION
 3. CRANIOTOMY

23. RADIATION
 Patients with brain metastasis require whole brain radiation
therapy(3000 cGy over 10 days).
 Intrathecal high dose methotrexate may be administered to
prevent haemorrhage and for tumour shrinkage.
 Liver metastasis: Interventional radiology(hepatic artery ligation or
embolization) or whole liver radiation(2000 cGy over 10 days)
along with chemotherapy may be effective.Hepatic metastasis has
a poor prognosis.

24. PROGNOSIS
 The cure rate is almost up to 100 percent in low risk and about 70
percent in high risk metastatic groups.
 Follow up is mandatory for all patients at least for 2 years.
 Serum hCG is measured weekly until it is negative for three
consecutive weeks. Thereafter it is measured monthly for 6 months
and 6 months thereafter for life.