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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 27  |  Issue : 2  |  Page : 159-161

Isolated relapse of choriocarcinoma in kidneys


Deparment of Urology, Regional Institute of Medical Sciences, Lamphelpat, Imphal, Manipur, India

Date of Web Publication19-Nov-2013

Correspondence Address:
Kangjam Sholay Meitei
Department of Urology, Regional Institute of Medical Sciences, Lamphelpat, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.121607

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  Abstract 

Gestational trophoblastic tumors are a spectrum of diseases spanning from a benign hydatidiform mole, through an invasive mole to a highly malignant form of choriocarcinoma. Choriocarcinoma is a rare, but the most malignant and aggressive neoplasm of all the gestational trophoblastic diseases. It metastasizes to the lungs, liver, and less frequently, the brain. Metastases to the kidneys are rare in the literature, and bilateral involvement is even rarer. It may mimic renal cell carcinoma. Here, we report a case of bilateral renal choriocarcinoma presenting six months after a history of hysterectomy for disorder uterine bleeding.

Keywords: Choriocarcinoma, Metastasis, Renal cell carcinoma, Renal tumors


How to cite this article:
Meitei KS, Akoijam KS, Khumukcham S, Sinam RS. Isolated relapse of choriocarcinoma in kidneys. J Med Soc 2013;27:159-61

How to cite this URL:
Meitei KS, Akoijam KS, Khumukcham S, Sinam RS. Isolated relapse of choriocarcinoma in kidneys. J Med Soc [serial online] 2013 [cited 2019 Dec 13];27:159-61. Available from: http://www.jmedsoc.org/text.asp?2013/27/2/159/121607


  Introduction Top


Gestational trophoblastic tumors (GTT) are a group of diseases spanning from a benign hydatidiform mole, through an invasive mole to a highly malignant form of choriocarcinoma. Choriocarcinoma is an uncommon, but it is the most malignant and aggressive neoplasm of all the GTTs. It can spread virtually anywhere in the body. Organs most commonly involved are the lung, vagina, central nervous system, liver, and gastrointestinal tract. Renal metastasis has been described in previous reports; however, they are uncommon especially with the advent of modern chemotherapy. In this report, we describe a rare case of metastatic choriocarcinoma, which presented with gross hematuria and clot colic secondary to renal metastasis. Right partial nephrectomy was performed to control the hematuria followed by chemotherapy.


  Case Report Top


A 40-year-old woman presented to us with gross hematuria with clot colic for 8-10 days without any complaint of coagulopathy, medication or trauma. She required multiple blood transfusions as she was quite pale. She gave past history of disorder uterine bleeding for which she underwent abdominal hysterectomy 6 months back. However, no histopathological report was available with us. Laboratory tests showed moderate anemia (Hemoglobinb = 7 mg/dl), elevated Erythrocyte Sedimentation Rate with normal blood clotting parameters. Renal function, liver function, and computed tomography thorax were normal. Abdominal ultrasonography demonstrated bilateral renal masses suggestive of renal cell carcinoma. MRI abdomen revealed tumors in both the kidneys. Right kidney had bifid pelvis and tumor was located in the upper pole. Left kidney had multiple tumors in both the poles [Figure 1] and [Figure 2]. Cystoscopic examination revealed the source of hematuria from the right side. So, a provisional diagnosis of bilateral renal cell carcinoma was made. She underwent right upper polar nephrectomy [Figure 3]. The post-operative period was uneventful and she got relieved from hematuria. Surprisingly, her histopathological report came as choriocarcinoma. Assessment of her serum beta- human chorionic gonadotropin level was 860 mIU/ml. The final diagnosis was bilateral metastatic renal choriocarcinoma. She was referred to the Oncology department for appropriate chemotherapy following stabilization of her general condition. After receiving four cycles of Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide (EMA-CO) regimen, her beta-human chorionic gonadotropin had normalized. Until her last follow-up one year after the last cycle of chemotherapy, her beta-HCG remained in normal level.
Figure 1 : MRI picture showing bilateral renal tumors

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Figure 2 : MRI picture showing right bifid renal pelvis

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Figure 3 : Intraoperative picture showing right partial nephrectomy in progress

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  Discussion Top


GTT are a group of diseases spanning from a benign hydatidiform mole, through an invasive mole to a highly malignant form of choriocarcinoma. Choriocarcinoma is an uncommon, but the most malignant and aggressive neoplasm of all the gestational trophoblastic diseases. [1] It is always associated with conception. [2] The most frequent sites of metastases are pulmonary and vaginal, but other abdominal viscera and brain may also be affected and renal involvement is rare. [3] The incidence of renal metastasis at autopsy varies from 1.8 to 11.8%; however, in clinical practice it occurs in less than 5% of patients presenting for initial chemotherapy. [4] Ogunbiyi reported two young Nigerian women in 1986, who presented with profuse hematuria and renal enlargement secondary to metastatic infiltration from choriocarcinoma in the absence of primary malignant uterine foci. [5] Soper reported eight cases of renal metastases of gestational trophoblastic disease with primary uterine tumors, and Wang presented a clinicopathological study on 31 cases of renal metastases of choriocarcinoma in 1991. [6] In 2005, Kheradmand reported the first case of choriocarcinoma that presented with bilateral renal masses without previous proven involvement of uterus. [7] Even though, we don't have a proven histopathogical report of primary uterine choriocarcinoma for the previous surgery available with us, we assumed that she had undergone hysterectomy for primary uterine choriocarcinoma. Lal et al. in 2009 reported a case of spontaneous renal hemorrhage and episodic gross hematuria in a patient with metastatic choriocarcinoma involving both kidneys for which successful angioembolisation was carried out for control of hemorrhage. [8]

Patients with high-risk metastatic gestational trophoblastic neoplasia International Federation of Gynecology and Obstetrics) stage IV and stages II-III score 7) should be treated initially with combination chemotherapy with or without adjuvant surgery or radiation therapy. [9] Combination chemotherapy, a combination of EMA-CO, results in improved remission and survival rates. Virtually, 50% of high-risk patients require surgical treatment during the course of treatment. [10]

In conclusion, this case demonstrates that metastatic choriocarcinoma can present with hematuria, clot colic, and bilateral renal masses mimicking renal cell carcinoma. Another interesting point in our case was the occurrence of bilateral renal metastases without metastasis to other organs. A high index of suspicion is important to diagnose these cases early and pre-operatively. Chemotherapy and/or surgery must be performed immediately after diagnosis, since both the modalities can cure alone or in combination.

 
  References Top

1.Vijay RK, Kaduthodil MJ, Bottomley JR, Abdi S. Metastatic gestational trophoblastic tumour presenting as spontaneous subcapsular renal haematoma. Br J Radiol 2008;81:e234-7.  Back to cited text no. 1
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2.Wagner BJ, Woodward PJ, Dickey GE. From the archives of the AFIP. Gestational trophoblastic disease: Radiologic-pathologic correlation. Radiographics 1996;16:131-48.  Back to cited text no. 2
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3.Small W Jr, Lurain JR, Shetty RM, Huang CF, Applegate GL, Brand WN. Gestational trophoblastic disease metastatic to the brain. Radiology 1996;200:277-80.  Back to cited text no. 3
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4.Thanikasalam K. Post-hysterectomy choriocarcinoma with pulmonary and renal metastases. Med J Malaysia 1991;46:187-91.  Back to cited text no. 4
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5.Ogunbiyi OA, Enweren EO, Ogunniyi JO. Unusual renal manifestations of choriocarcinoma. Afr J Med Med Sci 1986;15:93-7.  Back to cited text no. 5
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6.Soper JT, Mutch DG, Chin N, Clarke-Pearson DL, Hammond CB. Renal metastases of gestational trophoblastic disease: A report of eight cases. Obstet Gynecol 1988;72:796-8.  Back to cited text no. 6
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7.Kheradmand A. Choriocarcinoma presenting as bilateral renal tumor: A case report. Urol J 2005;2:52-3.  Back to cited text no. 7
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8.Lal A, Singhal M, Kumar S, Bag S, Singh SK, Khandelwal N. Bilateral renal and jejunal metastasis of choriocarcinoma presenting as spontaneous renal hemorrhage. Cancer Imaging 2009;9:56-8.  Back to cited text no. 8
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9.Alazzam M, Tidy J, Hancock BW, Osborne R. First line chemotherapy in low risk gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2009;1:CD007102.  Back to cited text no. 9
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10.Lurain JR, Singh DK, Schink JC. Role of surgery in the management of high-risk gestational trophoblastic neoplasia. J Reprod Med 2006;51:773-6.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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