less than 5% of patients with metastatic gestational trophoblastic neoplasia ( gtn ) have initial involvement of the gastrointestinal tract . although the role of surgery in metastatic choriocarcinoma has diminished , local resection of metastases still seems to play a role in a small subset of patients . here , we present a case of chemo - resistant choriocarcinoma , metastatic to the colon , which was salvaged by surgery . in september 2000 , a 48-year - old woman , gravid 4 para 2 , presented with acute abdominal pain and hypovolemic shock . her initial blood pressure was 82/56 mm hg , pulse rate was 112 beats / minute , and initial hemoglobin was 7.6 g / dl . the postoperative human chorionic gonadotropin ( hcg ) level was 34 miu / ml and was normalized during the four cycles of methotrexate and folic acid rescue ( mtx - cf ) after the operation ( table 1 ) . in january 2002 , the hcg level was elevated ( 64.9 miu / ml ) and abdomen - pelvis magnetic resonance imaging ( mri ) showed a soft tissue nodular mass adherent to the inferoposterior wall of the sigmoid colon . there was no evidence of metastases in other sites on the abdomen - pelvis mri , chest computed tomography ( ct ) , and brain ct . four cycles of combination chemotherapy with emaco ( weekly alternating etoposide , methotrexate , actinomycin d / vincristine , and cyclophosphamide ) were administered , and the hcg level was normalized following the 2nd cycle . her hemoglobin value was 4.7 g / dl , and the hcg level was 154,380 miu / ml . diffuse irregular wall thickening of the rectosigmoid colon with regional lymphadenopathy was identified in the abdomen - pelvis mri ( fig . three months after the chemotherapy , the hcg level had again risen up to 657 miu / ml . the positron emission tomography ( pet ) scan revealed increased fludeoxyglucose uptake ( suvmax=9.9 ) in the rectosigmoid colon ( fig . sigmoidoscopic findings showed stenosis and a protruding mass 14 cm above the anal verge junction . a secondary cytoreductive surgery for chemo - resistant choriocarcinoma was performed and a huge ulcerative mass appeared at the rectosigmoid junction . low anterior resection with lymphadenectomy up to the level of the inferior mesenteric artery was performed with no residual mass . the histological examination confirmed metastatic choriocarcinoma involving from the mucosa to the subserosa of the sigmoid colon ( fig . after the operation , the hcg level dropped from 6,298 miu / ml to 2.8 miu / ml . however , there has been no evidence of recurrence for 13 months since the operation . we have described a rare case of metastatic gtn responsive to surgery . in this case , the chemo - resistant gtn was treated with low anterior resection . therefore , the role of surgery in the treatment of patients with metastatic choriocarcinoma has diminished . the role of surgery in the treatment of metastatic choriocarcinoma has long been debated . in general , resection of distant metastasis in the 1960s , lewis and his associates documented that the common indications for surgery in gtn were the need for controlling hemorrhage , removing residual disease when resistant to chemotherapy , relieving urologic obstruction , and treating infection . also , local resection of metastases still seems to play a significant role even in curing the disease in a small subset of patients . common sites of metastases outside the pelvis are the lung , liver , and kidney . although risk factor of colonic metastases is not known , it is assumed that previous uterine perforation is associated with colonic recurrence . it is not known whether intestinal metastases would place patients at a higher risk of treatment failure . however , bowel resection may be beneficial in selected patients with intestinal metastases resistant to chemotherapy . all patients with high - risk should be treated with intensive combination chemotherapy and the selective use of radiation therapy and surgery . recently , several authors reported favorable results with salvage surgery for chemotherapy - resistant gtn . hysterectomy may be necessary to control uterine hemorrhage or sepsis , or to resect resistant disease . hepatic resection may be required to manage bleeding metastases although embolization has also been utilized in this setting . craniotomy may be necessary to provide acute decompression or to control bleeding , in addition to its role in the primary resection of solitary metastatic disease . have suggested that age older than 35 years , antecedent non - molar pregnancy , distant metastasis outside of the lungs and uterus , and a preoperative serum -hcg level greater than 10 iu / l are important clinical predictors of treatment failure , which will require following surgery . a pet scan may be useful to identify occult sites of viable tumor . in conclusion , although combination chemotherapy is the main treatment used in patients with high - risk gtn , surgical intervention may occasionally be required . in this case , surgery was effective for the cure of chemo - refractory choriocarcinoma , metastatic to the colon .
the role of surgery in the treatment of patients with metastatic choriocarcinoma has diminished . 
 we present a case of chemo - resistant metastatic choriocarcinoma salvaged by surgery . a 48-year - old patient presented with uterine perforation and severe intractable hemorrhage , and histological examination revealed a choriocarcinoma . 
 after 6 years of disease - free state , recurrence occurred in the rectosigmoid colon . 
 seven cycles of emaco chemotherapy was administered , and the human chorionic gonadotropin level was normalized . 
 three months after the chemotherapy , the rectosigmoid colon metastasis progressed . 
 low anterior resection with lymphadenectomy up to the level of the inferior mesenteric artery was conducted . 
 after the operation , the human chorionic gonadotropin level decreased to within the normal range . 
 there has been no evidence of disease for 13 months since the operation . 
 local resection of metastases seems to play a significant role in curing the disease in a small subset of patients .