PMC8841587_01
The pathological findings were choriocarcinoma accompanied with extensive hemorrhage and necrosis (100x, A). The tumor consists of syncytiotrophoblastic cells and cytotrophoblastic cells, which were characterized as medium-sized, whereas the peripheral one was composed of large, multinucleated cells (200x, B).
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Microscopically, the necrotic tissue showed the plexiform pattern with triphasic differentiation into cytotrophoblast, syncytiotrophoblast, and intermediated trophoblast and marked cytologic atypia, confirmed as metastatic choriocarcinoma ( Figure 1 ).
MRI film showing the original lesion in the anterior uterine wall (A) and the metastasis lesion in the bilateral pulmonary tissue (B), right lobe of the liver (C), and the vagina (D).
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A comprehensive examination was performed: color doppler ultrasonography showed a single intrauterine pregnancy at 28 gestational weeks, and dilation of the muscular vessels in the anterior uterine wall; chest computed tomography (CT) revealed more than 10 multiple lung metastases with the largest lesion about 3.0x1.9 cm; abdominal magnetic resonance (MR) presented a 3.2x2.1 cm hemorrhagic tumor in the right lobe of liver; pelvic MR revealed extensive hematocele between the anterior uterine wall and amniotic sac with the thickness of about 6 mm, and a 39x31x31 mm metastatic lesion in the vagina, without fetal metastasis; head MR revealed no brain metastasis; the level of serum beta-hCG was 26,603 mIU/ml (normal <5 mIU/ml, range for gestational age of 29 weeks 940-60,000 mIU/ml) ( Figure 2 ).
(A) Results for the different markers located on the chromosome Y. All markers included DYS576, DYS389I/II, DYS448, and DYS19 indicated the chromosome Y in the placenta and choriocarcinoma originated from one paternal genotype. (B) The markers D3S1358, D16S539, TH01, D8S1179, D12S391, D19S433, FGA indicated autosomal STR of choriocarcinoma was different from that of the placenta tissue.
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According to the genotype, the choriocarcinoma showed a signal on Y-chromosome, which matched that of the placenta ( Figure 3A ). TH01, D8S1179, D12S391, D19S433, FGA,  Figure 3B ). Therefore, the choriocarcinoma tissue was not derived from the fourth child or the patient, and the third spontaneous abortion was speculated to be the origin.
The vaginal metastasis choriocarcinoma, which contained blood clots and necrotic tissue before chemotherapy (A), at 30 days postdelivery (B), at 90 days postdelivery when finished with EMA/CO chemotherapy (C).
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After three cycles, the beta-hCG value was 0 mIU/ml, and vaginal metastases vanished completely ( Figure 4 ).