Journal List > Korean J Obstet Gynecol > v.53(11) > 1006365

Korean J Obstet Gynecol. 2010 Nov;53(11):1024-1027. English.
Published online November 30, 2010.  https://doi.org/10.5468/kjog.2010.53.11.1024
Copyright © 2010 Korean Society of Obstetrics and Gynecology
Video-assisted thoracoscopic surgery for pulmonary metastasis of gestational trophoblastic neoplasia
Yong-Seok Kim, M.D., Hye-Min Kwak, M.D., Seo-Hee Kim, M.D., Chel-Hun Choi, M.D., Jeong-Won Lee, M.D., Ph.D. and Duk-Soo Bae, M.D., Ph.D.
Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Corresponding author (Email: ds123.bae@samsung.com )
Received August 04, 2010; Revised September 30, 2010; Accepted October 06, 2010.

Abstract

Gestational trophoblastic neoplasm (GTN) is prone to pulmonary metastasis. Although most pulmonary metastatic lesions response with chemotherapy, some lesions do not resolve and persist on radiologic investigations. A 25-year-old women was referred for persistent pulmonary metastatic lesion of GTN. Here, we present a case of chemo-resistant choriocarcinoma metastatic to lung managed by video-assisted thoracoscopic surgery.

Keywords: Gestational trophoblastic neoplasm; Thoracic surgery; Video-assisted


Gestational trophoblastic neoplasm (GTN) tends to hematogenous metastasis, especially to the lungs. After several courses of chemotherapy, residual pulmonary lesions have to be managed with further treatments.

The role of surgery for pulmonary metastasis is not fully defined. Thoracotomy sometimes has played a role in the management of pulmonary metastasis. Prior series have reported a wide range for the rate of surgery for pulmonary metastasis in choriocarcinoma ranging from 1% to 17%.1

As a result of advances in surgical technique, resection of pulmonary metastasis can be accomplished in a less invasive manner with thoracoscopic surgery. We present a case of chemo-resistant choriocarcinoma metastatic to lung managed by video-assisted thoracoscopic surgery.

Case Report

The patient is 25-year-old gravida 2 para 0 women. She had a past history of two spontaneous abortion. She visited to a local clinic in 1/25/2005 for amenorrhea for 7 weeks. Her serum β-human chorionic gonadotropin (β-hCG) was 311 mIU/mL. On pelvic ultrasonography, she had a normal appearance of uterus, fallopian tubes, and ovary. Based on the patient's history, an ectopic pregnancy was suspectd. She received 50 mg/m2 methotrexate on 1/28/2005 and was then offered a uterine curretage. The pathologic result of endometrial curretage was consistent with endometrial polyp. Her serum β-hCG rose to 291 mIU/mL over the next 2 weeks. We checked the serum β-hCG weekly and gave the methotrexate injected twice. It rose to 504 mIU/mL on 5/3/2005. She was referred to SAMSUNG Medical Center for further evaluation and treatment. On presentation to the gynecologic oncology service, positron emission tomography (PET) and computerized tomography (CT) scan of the chest revealed intense focal increased fluoro-D-glucose (FDG) uptake in uterine cavity and two hypermetabolic pulmonary nodules in both upper lungs, suspected metastatic nodule (Fig. 1). The size of two nodule was 2 cm, 1.8 cm respectively. But, no specific abnormalities were found in pelvis MRI. Her serum β-hCG was 620 mIU/mL. On admission, the patient was treated with 5 cycles of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO) regimen as chemotherapy. Her β-hCG showed the nadir after 2 cycles of chemotherapy and thereafter continued to normal range to the last cycle. A repeated chest CT and PET demonstrated decreased size of the pulmonary nodules less than 1cm, both and marked decreased of abnormal FDG uptake in uterine cavity. But, on routine following up, serum β-hCG gradually increased to 24.4 mIU/mL on 1/5/2006. and On repeated PET, increased FDG uptake in the pulmonary nodule of left upper lobe was discovered and a pulmonary nodule without significant FDG uptake in the right upper lobe of lung, benign lesion more likely. The patient underwent video-assisted thoracoscopy with pulmonary wedge resection on 2/7/2006. About 1.7cm sized mass was resected from left upper lobe. Resected mass was pathologically revealed with metastatic choriocarcinoma (Fig. 2). Postoperatively, the patient was treated with 2 cycle of adjuvant etoposide, methotrexate, actinomycin D, cisplatin (EMA-EP) regimen as chemotherapy. Her serum β-hCG showed the normal range after surgery. She had been followed with serial PET and serum β-hCG. She was without evidence of disease 46 months after the last chemotherapy.


Figure 1
(A) Positron emission tomography showing pulmonary metastasis of left upper lobe. (B) Chest computerized tomography showing pulmonary metastasis.
Click for larger image


Figure 2
(A) Low power view of microscopic finding shows diffuse hemorrhage and necrosis of the tumor (×40). (B) The tumor is composed of cytotrophoblast and syncytiotrophoblastic giant cells with irregular arrangement (×200). (C) Immunohistochemical stain for β-hCG highlights the cytoplasm of the syncytiotrophoblastic giant cells (hCG ×400).
Click for larger image

Discussion

With the development of chemotherapy, the prognosis of choriocarcinoma has been substantially improved; even patients with extensive disease can be salvaged.2 Prior series have noted pulmonary metastasis as many as 70% of metastatic GTN.1, 3 Since the first report by Shirley et al, there have been several reports of the use of thoracotomy in patients metastatic to lung.

The role of surgery in the management of metastatic GTN has long been controversial. Usually, tumors are treated with chemotherapy alone. However there are numerous refractory cases in which surgical removal of pulmonary metastasis may be important to effect a cure. Surgical resection of pulmonary metastasis of GTN was originally reported by Maier and Taylor.4 Because of tendency of GTN to metastasis to the lungs, thoracotomy has been used in the management of local and metastatic disease. Nontheless, the indications for thoracotomy is not fully defined, and currently, the role of thoracotomy in the management of GTN is limited.

As a result of development in surgical technique, video-assisted thoracoscopic surgery has become accepted a safe and effective procedure to treat wide range of lung diseases. video-assisted thoracoscopic surgery's advantages include less postoperative pain and shorter length of hospital stay.

There were some reports that patients achieved nomal β-hCG titer after pulmonary resection and remained in remission without additional chemotherapy.1, 5 But, our patient with nomal β-hCG titer after surgery was given 2 courses of chemotherapy. We suggested that postoperative chemotherapy was essential, especially for chemo-resistant, recurrent patients, because nomal β-hCG titer could not have confidence absence of active trophoblastic cells, which could be the origin of recurrence. However, further investigation is needed.

In conclusion, while multiagent chemotherapy is still standard treatment for GTN metastatic to lung, surgical resection with thoracoscopy can be a minimal invasive and effective therapeutic method for patients with chemo-resistant disease.

References
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2. Song HZ, Yang XY, Xiang Y. In: Trophoblastic tumors diagnosis and treatment. Beijing: People's Medical Publishing House; 2004.
3. Tow WS, Cheng WC. Recent trends in treatment of choriocarcinoma. Br Med J 1967;1:521–523.
4. Maier HC, Taylor HC. Metastatic choriocarcinoma of the lung treated by lobectomy. Am J Obstet Gynecol 1974;53:674–677.
5. Jones WB, Romain K, Erlandson RA, Burt ME, Lewis JL Jr. Thoracotomy in the management of gestational choriocarcinoma. A clinicopathologic study. Cancer 1993;72:2175–2181.