PMC4921190_01
Placental pathology revealed a small (2.5 cm x 2.0 cm x 2.0 cm) nodular placental lesion consistent with trophoblastic disease. Choriocarcinoma is characterized by abnormal trophoblastic hyperplasia and anaplasia (black arrows), absence of chorionic villi, hemorrhage, necrosis (white arrows), and direct invasion into the myometrium. (H&E stain, 100x magnification)
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Her placental pathology revealed a small nodular placental lesion consistent with trophoblastic disease (Fig. 1).
Diagnostic CT scan of the chest (a, b) revealed a bilobed right-upper-lobe pulmonary lesion measuring 1.4 cm AP x 2.1 cm TV x 1.8 cm CC. Lungs are the most common site of metastasis for choriocarcinoma, accounting for 76%-87% of metastases, and it is rare to have additional metastatic sites in the absence of lung metastases. A CT scan of the abdomen also demonstrated bilateral contrast-enhancing renal lesions measuring 2.7 cm AP x 2.6 cm TV x 3.5 cm CC in the right upper pole (c, d) and 2.7 cm AP x 2.4 cm TV x 4.2 cm CC in the left lower pole (e, f). The left renal lesion was also associated with a large retroperitoneal hematoma measuring approximately 22 cm in CC dimension. Choriocarcinoma is a hypervascular tumor and is often associated with bleeding; as a result, biopsy of metastatic lesions is not routinely performed, as it may result in excessive bleeding.
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She also underwent diagnostic CT scans of the chest, abdomen, and pelvis that revealed a right-upper-lobe pulmonary lesion, bilateral renal lesions, and an associated left-sided retroperitoneal hematoma (Fig. 2).
A head CT scan revealed a 4-mm contrast-enhancing focus in the left parietal lobe (a, b). Subsequent MRI demonstrated the solitary lesion (c, d). A susceptibility-weighted sequence (e) revealed that the lesion was associated with hemorrhage, further raising concern for metastatic choriocarcinoma. No other intracranial metastases were identified.
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A subsequent MRI demonstrated the solitary lesion, with no other intracranial metastases identified (Fig. 3).
An abdomen/pelvis CT scan was performed after the patient represented to the emergency department two days after discharge with symptoms of nausea, vomiting, severe abdominal pain radiating to the left flank, weakness, and a hemoglobin drop from 10.0 g/dL on discharge to 8.4 g/dL on readmission. Imaging revealed interval development of a right-sided subcapsular hematoma extending from the previously visualized right renal lesion (a, b) and interval increased size of the large left renal mass (c, d), now measuring approximately 5.2 cm AP x 3.7 cm TV x 5.3 cm CC, with interval increase in associated retroperitoneal hematoma now measuring 27 cm in CC dimension. The patient was subsequently taken to interventional radiology for possible embolization; however, renal arteriography did not reveal a hypervascular lesion or active extravasation.
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An abdomen/pelvis CT scan revealed increased size of the large left retroperitoneal hematoma and interval development of a new retroperitoneal hematoma (Fig. 4).