What is Choriocarcinoma?
Gestational trophoblastic diseases, which were first identified by Hippocrates in 400 BC, encompass a variety of conditions including a rare and aggressive one known as choriocarcinoma. Choriocarcinoma has two main types: gestational and non-gestational, and each type behaves differently and has distinct outcomes. While choriocarcinoma commonly affects women, it can also occur in men typically as an element of a mixed germ cell tumor.
What Causes Choriocarcinoma?
Choriocarcinoma is a type of cancer that develops from an abnormal group of cells that play a crucial role in early pregnancy. It is associated with uncontrolled cell growth and changes, most commonly following a molar pregnancy, which is a rare condition where the placenta becomes a mass of cysts.
There are two types of choriocarcinoma: gestational and non-gestational. Gestational choriocarcinoma develops after a molar pregnancy, normal pregnancy, or most commonly, a miscarriage. On the other hand, non-gestational choriocarcinoma develops from very versatile germ cells, cells that can develop into many different types of cells.
Non-gestational choriocarcinomas can form in both men and women, in the reproductive organs, or other structures in the body that contain these versatile germ cells.
Risk Factors and Frequency for Choriocarcinoma
Choriocarcinoma is a very rare type of tumor. Its occurrence varies further around the world. In Europe and North America, about 1 in 40,000 pregnant patients and 1 in 40 patients carrying a type of tumor known as a hydatidiform mole are likely to develop choriocarcinoma. The rates are higher in Southeast Asia, Japan, and China, where it might affect more pregnant women and those carrying hydatidiform moles.
Furthermore, certain groups, such as Asian, American Indian, and African American women, are more likely to develop choriocarcinoma. Other risk factors include a history of hydatidiform mole, advanced age, long-term oral contraceptive use, and blood type A.
- In Europe and North America, around 1 in 40,000 pregnant patients and 1 in 40 patients with hydatidiform moles might develop choriocarcinoma.
- In Southeast Asia and Japan, it’s 9.2 in 40,000 pregnant women and 3.3 in 40 hydatidiform mole patients.
- In China, 1 in 2,882 pregnant women may develop it.
- This rare type of tumor forms less than 0.1% of primary ovarian tumors.
- In men, who are usually aged between 20 to 30, this constitutes less than 1% of testicular tumors.
- However, mixed germ cell tumors in which choriocarcinoma is a component occur much more frequently in the testicles, making up to 15% of such tumors.
Signs and Symptoms of Choriocarcinoma
If a patient is suspected to have choriocarcinoma, it’s crucial for healthcare professionals to carry out a detailed health history check and physical examination. When it comes to women, doctors should pay extra attention to their reproductive history, as instances like spontaneous miscarriages and molar pregnancies can increase the chances of developing this type of cancer. Bleeding after menopause should also be seen as a possible warning sign.
Choriocarcinoma tends to spread to other parts of the body, so any symptoms indicating issues in other organs, such as coughing up blood or bleeding in the digestive system, should be noted.
- Check detailed health history
- Perform physical examination
- Pay extra attention to a woman’s reproductive history
- Consider post-menopausal bleeding as suspicious
- Note symptoms of complications in other organs
Patient’s might show signs like abnormal uterine bleeding, development of breasts in men (gynecomastia), or overactivity of the thyroid gland (hyperthyroidism) due to a rise in the levels of a hormone called human chorionic gonadotropin (hCG).
Men with choriocarcinoma typically show signs of the disease spreading to other parts of the body. Often, this includes symptoms like coughing up blood, but the liver, digestive system, and brain can also get affected.
Testing for Choriocarcinoma
To check for a disease called choriocarcinoma, various blood tests are used. These may include a complete blood count, tests that look at how your blood clots, checks of your general body chemistry, and exams of how well your kidneys and liver are working. Other tests might look for a specific hormone in your body called hCG.
In the UK, doctors start chemotherapy to treat a related condition, gestational trophoblastic disease, based on several signs. These include plateaus or rises in hCG levels after removing a potentially cancerous growth from the uterus and heavy vaginal bleeding. Other signs can be bleeding in the stomach or protective lining of the abdomen, confirmed choriocarcinoma through testing of tissue samples, metastases (when cancer spreads) to the brain, liver, or gastrointestinal tract, and certain lung abnormalities. If the hCG hormone is relatively high a month after removal of the growth or still present six months later (even if decreasing), chemotherapy may be necessary.
Once a patient has been diagnosed with choriocarcinoma, it’s essential to check if the disease has spread to other parts of the body. The most common place the disease spreads to is the lungs. Doctors recommend performing a CT scan of the chest, abdomen, and pelvis due to the disease’s tendency to spread. Also, they recommend checking the brain with a CT scan or an MRI.
In men who have choriocarcinoma, the testicles are usually very small or may have even shrunk with only cancerous cells and those that have spread elsewhere remaining.
Treatment Options for Choriocarcinoma
When it comes to a type of cancer known as choriocarcinoma, the treatment options will depend on a few factors. If the risk is low (this is determined by a score of less than 7, which we determine through a process called staging) and the cancer is at stage I, II, or III, a single treatment of either methotrexate or actinomycin D chemotherapy can be used.
If the risk is high (a score greater than 7), and the cancer is at stage II, III, or IV, a combination of treatments is used. These can include chemotherapy with multiple drugs, radiation therapy and surgery.
After treatment is completed and the levels of hCG – a hormone that serves as a marker for the disease – have returned to normal, regular checks are needed. The hCG levels should be checked once a month for a year, along with two physical exams during the same period.
In case of a pregnancy following treatment, an ultrasound during the first trimester is highly recommended. This is to check that the pregnancy is in the uterus, due to a small chance of choriocarcinoma returning. Additionally, the placenta should be tested to check for recurrence of the cancer.
What else can Choriocarcinoma be?
When trying to determine the correct diagnosis, doctors might consider several conditions with similar symptoms, such as:
- Placental Site Trophoblastic Tumor
- Seminoma (a kind of testicular cancer)
- Mixed Germ Cell Tumor (a type of testicular cancer that contains many different types of cancerous cells)
- Solid Variant of Yolk Sac Tumor (a rare, aggressive form of cancer often found in children)
- Embryonal Carcinoma (a type of cancer that can occur in the ovaries or testicles).
It’s crucial for doctors to thoroughly review these potential conditions and conduct necessary tests to make an accurate diagnosis.
Surgical Treatment of Choriocarcinoma
In about half of the patients diagnosed with high-risk choriocarcinoma, a type of cancer, medical professionals use a combination of surgery and chemotherapy as treatment. Specifically, surgery is done to remove the uterus or areas where the cancer has spread.
What to expect with Choriocarcinoma
Gestational and non-gestational choriocarcinoma, two types of cancers that start in the uterus, have different outcomes. Non-gestational choriocarcinoma tends to be more severe and responds less effectively to chemotherapy. Genetic testing helps to distinguish both types; gestational choriocarcinoma usually has chromosomes typical of a father, whereas non-gestational choriocarcinoma has DNA similar to the patient and may present certain abnormal chromosome patterns.
Predicted survival rates for gestational choriocarcinoma are very high. Almost all women with low-risk gestational choriocarcinoma recover fully after chemotherapy. For high-risk cases, survival rates range from 91% to 93% when treatment involves multiple types of chemotherapy, and in some cases, radiation and surgery. Certain risk factors may weaken the prognosis, such as stage IV disease or a cumulative score higher than 12 in women.
For men with mixed germ cell tumors, an increased presence of choriocarcinoma cells indicates a worse prognosis. Pure choriocarcinomas mark the worst prognosis in testicular germ cell neoplasms. Also, an hCG level greater than 50,000 mIU/ml signals a worse prognosis in men.
The prognosis for intra-placental choriocarcinoma, a cancer that starts inside the placenta and spreads to the infant, is particularly serious. Less than 20% of cases survive.
Possible Complications When Diagnosed with Choriocarcinoma
Choriocarcinoma, if left untreated, could lead to death. However, the introduction of chemotherapy has allowed many patients to successfully treat and even cure their disease. Despite its potential benefits, chemotherapy does come with several risks. These can include developing other types of cancer, feeling nauseous, vomiting, losing hair, getting diarrhea, experiencing fevers and infections, and needing a blood transfusion.
Potential Risks of Chemotherapy:
- Development of other types of cancer
- Nausea
- Vomiting
- Hair loss
- Diarrhea
- Fevers
- Infections
- Need for a blood transfusion
Preventing Choriocarcinoma
Women who go through a molar pregnancy, be it full or partial, need to be made aware of the potential risk of developing a type of cancer called choriocarcinoma. It’s crucial for these women to be monitored closely, watching out for changes in their hCG levels – a kind of hormone. Every woman, especially those at higher risk, who has recently given birth, should be advised to return for checks if she continues to experience bleeding even after childbirth.