- Citado por SciELO
versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. v.96 n.1 Madrid ene. 2004
Gastrointestinal hemorrhage due to metastatic choriocarcinoma
with gastric and colonic involvement
J. Molina Infante, I. Beceiro Pedreño, C. Ripoll Noiseux, I. Marín Jiménez, C. González Asanza and
P. Menchén Fernández-Pacheco
Department of Gastroenterology. Endoscopy Unit. Hospital General Universitario Gregorio Marañón. Madrid, Spain
Metastatic choriocarcinoma is a rare nonseminomatous germ-cell tumor with a characteristic hemorrhagic tendency due to its trophoblastic origin. Gastrointestinal tube involvement is present in less than 5% of cases, and location or therapy of these lesions can be achieved by endoscopy, angiography or surgery. Despite its being a highly curable malignant disease, the ocurrence of gastrointestinal bleeding worsens prognosis. We report a case of metastatic choriocarcinoma which manifested as melaena and was diagnosed by the presence of metastatic lesions in the stomach and right bowel on endoscopy.
Key words: Choriocarcinoma. Gastrointestinal hemorrhage.
Molina Infante J, Beceiro Pedreño I, Ripoll Noiseux C, Marín Jiménez I, González Asanza C, Menchén Fernández-Pacheco P. Gastrointestinal hemorrhage due to metastatic choriocarcinoma with gastric and colonic involvement. Rev Esp Enferm Dig 2004; 96: 77-80.
Correspondencia: J. Molina Infante. Servicio de Aparato Digestivo. Hospital General Universitario Gregorio Marañón. Dr. Esquerdo, 46. 28007 Madrid. Telfs.: 915868300 / 627430248. e-mail: email@example.com.
Tumoral metastatic disease involving the gut is an infrequent event that may result in gastrointestinal hemorrhage. In most cases, a diagnosis is casually reached during autopsy, radiological techniques or surgical procedures. Tumors most frequently associated with gut metastases include melanoma, lung and breast cancer, renal cell carcinoma, germ-cell tumours, and head and neck tumors (1).
In patients with wide-spread tumoral disease and gastrointestinal hemorrhage, endoscopic management should be individualized according to personal and clinical characteristics, in order to obtain etiological information on the hemorrhage, a histological examination of potential bleeding lesions, and endoscopic therapy when necessary.
A 37-year-old man with no significant medical or surgical history was admitted because of fatigue, weight loss, fever up to 38 ºC, and moderate hematuria during the last month. Physical examination was normal. Laboratory testing showed anaemia (haemoglobin 7.7 g/L), fibrinogen 838 mg/dL, and LDH 2811 mg/dL. On a chest x-ray several bilaterally spread nodules were seen, with sizes ranging from 2 to 8 centimeters, and an abdominal CT scan demonstrated similar lesions in the liver, spleen, kidneys and bladder. No mediastinal or retroperitoneal masses were observed, and a testicular ecography was normal.
Seven days after admission the patient presented melaena and hypotension, which required blood transfusion. Endoscopy showed a 3 cm submucosal mass with a central deep ulceration in the upper body of the stomach, but no blood was found. The procedure was not completed because of patient intolerance. Beta- human chorionic gonadotropin was 9.281 mIU/mL (normal less than 5.0), with no positivity for other tumour markers. Due to the absence of blood in upper endoscopy, a colonoscopy was performed. Two polypoid masses in the right bowel were shown (Fig. 1). On histologic examination a poorly differentiated glandular carcinoma suggestive of choriocarcinoma was detected.
Despite the fact that a primary tumour location was not found, cisplatin-based combination chemotherapy was started; however, the patient unfortunately died three weeks later.
Non-gestational choriocarcinoma is a rare trophoblastic germ-cell tumour with a characteristically agressive spread through the lymph and blood from the retroperitoneal space, mediastinum and gonads. Because of its origin, metastatic lesions produce beta-human chorionic gonadotropin; they also have a hemorrhagic tendency that results in the disease often presenting with bleeding from metastatic lesions. Metastatic disease is usually located in the lung, brain, bones, and lymph nodes, and it involves the gut in less than 5% of cases (2). In such cases the stomach, usually the upper body, is the most common location, with a few case reports on the small intestine and colon (3-7). No prior report of simultaneous gastric and colonic hemorrhagic lesions has been described at the onset of this disease.
In any metastatic neoplasm implantation takes place in the submucosa once tumour cells reach the gastrointestinal tract, as they fail to pass through the capillary barrier. As this submucosal tumour grows, blood supply to its central area decreases, which gives rise to erosions and ulcerations. For this reason, the main morphologic endoscopic features of metastatic gastrointestinal lesions are ulcerated submucosal and polypoid masses (1), which may require a more aggressive biopsy technique in order to obtain proper histological material.
Tumoral specific markers are an important diagnostic tool. Beta-human chorionic gonadotropin serum concentrations are increased in all patients with pure choriocarcinoma and alpha-fetoprotein concentrations may be elevated in 30-60% of choriocarcinomas, usually in mixed histological forms with other germ-cell tumours.
Metastatic choriocarcinoma is a malignant disease with a high remission rate and a 5-year overall survival rate of 70-80%. Main prognostic factors include chemorefractory status, beta human gonadotropin serum concentrations higher than 1000 mIU/mL, and a primary mediastinal tumour. However, the occurrence of gastrointestinal hemorrhage due to metastatic lesions and also promoted by chemotherapy adverse effects worsens the prognosis. The treatment of choice is a high-dose cisplatin-based chemotherapy, and the role of coadjuvant peripheral blood stem-cell transplantation is being evaluated in clinical trials (8).
The specific treatment of gastrointestinal bleeding metastatic disease is controversial because accurate topographic mapping of the lesions by endoscopy, laparoscopy or angiography would be needed. In recent years, there have been some reports on laparoscopic surgery for isolated gastric and jejunal lesions (3,7,9), and angiographic embolization (5), but no survival benefit has been proven with these approaches.
In every young man with widespread, unidentified tumoral disease and various hemorrhagic symptoms, a germ-cell tumour should be ruled out by testicular ecography, thoracic and abdominal scans, and beta-human chorionic gonadotropin and alpha-fetoprotein serum concentrations. In the case of gastrointestinal hemorrhage, a panendoscopic examination and histologic evaluation should be carried out to identify metastatic lesions and provide potential endoscopic therapy; should this be not practical, angiography and surgery might prove useful for the control of active tumour bleeding.
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