FIGURE 20-5 Metastatic choriocarcinoma. A. Chest radiograph demonstrates widespread metastatic lesions. B. Autopsy specimen with multiple hemorrhagic hepatic metastases. (Used with permission from Dr. Michael Conner.) cases follow a molar gestation (Soper, 2006). Choriocarcinoma is composed of cells reminiscent of early cytotrophoblast and syncytiotrophoblast, however, it contains no villi. his rapidly growing tumor invades both myometrium and blood vessels to create hemorrhage and necrosis. Myometrial tumor may spread outward and become visible on the uterine surface as dark, irregular nodules. Metastases often develop early and are generally blood-borne (Fig. 20-5). The most common sites are the lungs and vagina, but tumor may travel to the vulva, kidneys, liver, brain, ovaries, and bowel. Bleeding can complicated these metastases (Fatema, 2016; Wei, 2016; Zhang, 2017). Choriocarcinomas are commonly accompanied by ovarian theca-lutein cysts.
This rare tumor arises from intermediate trophoblasts at the placental site. hese tumors have associated serum �-hCG levels that may be only modestly elevated. However, they produce variant forms of hCG, and identiication of a high proportion of free �-hCG is considered diagnostic. Treatment of placental site trophoblastic tumor by hysterectomy is preferred because these locally invasive tumors are usually resistant to chemotherapy (Baergen, 2006). For higher-risk stage I and for later stages, adjuvant multidrug chemotherapy is also given (Schmid, 2009).
This rare tumor develops from chorionic-type intermediate trophoblast. he uterus is the main site of involvement, and bleeding and low hCG levels are typical findings (Scott, 2012). Primary treatment is hysterectomy because this tumor is relatively resistant to chemotherapy. Metastatic disease is common, and combination chemotherapy is employed (Davis, 2015) .
Women with GTN are best managed by oncologists, and some (Kohorn, 2014). The prognosis is excellent with rare excep tions, and patients are routinely cured even in the presence of widespread disease. Chemotherapy alone is usually the primary treatment. Although controversial, some also consider a sec ond uterine evacuation to be an adjuvant therapeutic option in some GTN cases to avoid or minimize chemotherapy (Pezeshki, 2004; van Trommel, 2005). In other cases, suction curettage may infrequently be needed to resolve bleeding or remove a sub stantial amount of retained molar tissue. In speciic cases, hys terectomy may be primary or adjuvant treatment (Clark, 2010).
Single-agent chemotherapy protocols are usually suicient for nonmetastatic or low-risk metastatic neoplasia (Lawrie, 2016). In their review of 108 women with low-risk disease, Abrao and colleagues (2008) reported that monotherapy protocols with either methotrexate or actinomycin D were equally efective compared with a regimen containing both. In general, methotrexate is less toxic than actinomycin D (Chan, 2006; Secki, 2010). Regimens are repeated until serum �-hCG levels are undetectable.
Combination chemotherapy is given for high-risk disease, and reported cure rates approximate 90 percent (Lurain, 2010). Several regimens have been used with success. One is EMA-CO, which includes �toposide, methotrexate, gctinomycin D, �yclophosphamide, and