Difference between revisions of "Choriocarcinoma"

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#redirect [[Germ cell tumours#Choriocarcinoma]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Choriocarcinoma_-2-_very_high_mag.jpg
| Width      =
| Caption    = Choriocarcinoma. [[H&E stain]].
| Micro      = cytotrophoblasts, syncytiotrophoblast (often wrapped around the cytotrophoblasts) - multinucleated, hemorrhage (very common), necrosis (common)
| Subtypes  =
| LMDDx      = [[mixed germ cell tumour]], [[invasive hydatidiform mole]], [[placental site trophoblastic tumour]]
| Stains    =
| IHC        = beta-hCG +ve, CD10 +ve, p63 +ve, OCT3 -ve
| EM        =
| Molecular  =
| IF        =
| Gross      = dark friable, hemorrhagic/necrotic-appearing mass with an invasive border
| Grossing  = [[orchiectomy grossing]]
| Staging    = [[testicular cancer staging]]
| Site      = [[ovary]], [[testis]], [[uterus]]
| Assdx      = [[complete hydatidiform mole]]
| Syndromes  =
| Clinicalhx = often preceded by [[pregnancy]]
| Signs      = testicular mass (male)
| Symptoms  = vaginal bleeding (female)
| Prevalence = rare
| Bloodwork  = beta-hCG markedly elevated (usu. >10,000 IU)
| Rads      =
| Endoscopy  =
| Prognosis  = often poor
| Other      =
| ClinDDx    =
| Tx        = surgery and chemotherapy
}}
'''Choriocarcinoma''' is a rare aggressive [[germ cell tumour]].
 
==General==
*Aggressive clinical course.
*Usually a mixed tumour, i.e. pure choriocarcinoma is rare, e.g. [[dysgerminoma]] + choriocarcinoma.
 
===Clinical===
*High beta-hCG -- usually > 10,000 IU.
**Median in one series of testicular choriocarcinoma ~ 200,000 IU.<ref name=pmid24145647>{{Cite journal  | last1 = Alvarado-Cabrero | first1 = I. | last2 = Hernández-Toriz | first2 = N. | last3 = Paner | first3 = GP. | title = Clinicopathologic analysis of choriocarcinoma as a pure or predominant component of germ cell tumor of the testis. | journal = Am J Surg Pathol | volume = 38 | issue = 1 | pages = 111-8 | month = Jan | year = 2014 | doi = 10.1097/PAS.0b013e3182a2926e | PMID = 24145647 }}</ref>
**Elevation may be seen in other (non-trophoblastic) tumours.<ref name=pmid7690985>{{Cite journal  | last1 = Mann | first1 = K. | last2 = Saller | first2 = B. | last3 = Hoermann | first3 = R. | title = Clinical use of HCG and hCG beta determinations. | journal = Scand J Clin Lab Invest Suppl | volume = 216 | issue =  | pages = 97-104 | month =  | year = 1993 | doi =  | PMID = 7690985 }}</ref>
*Vaginal bleeding or testicular mass.
*Occasionally thyrotoxicosis.<ref name=pmid8395487>{{Cite journal  | last1 = O'Reilly | first1 = S. | last2 = Lyons | first2 = DJ. | last3 = Harrison | first3 = M. | last4 = Gaffney | first4 = E. | last5 = Cullen | first5 = M. | last6 = Clancy | first6 = L. | title = Thyrotoxicosis induced by choriocarcinoma a report of two cases. | journal = Ir Med J | volume = 86 | issue = 4 | pages = 124, 127 | month =  | year =  | doi =  | PMID = 8395487 }}</ref>
 
Note:
*Beta-hCG is negative ~3 weeks after pregnancy.<ref name=pmid2436389 >{{Cite journal  | last1 = Haenel | first1 = AF. | last2 = Hugentobler | first2 = W. | last3 = Brunner | first3 = S. | title = [The postpartum course of the HCG titer of maternal blood and its clinical relevance]. | journal = Z Geburtshilfe Perinatol | volume = 190 | issue = 6 | pages = 275-8 | month =  | year =  | doi =  | PMID = 2436389 }}</ref>
 
===Epidemiology===
*May be preceded by a [[complete hydatidiform mole]].<ref name=Ref_PBoD1110-1>{{Ref PBoD|1110-1111}}</ref>
*More common in the far east.
*More common at extremes of fertile age (teens and 40-50 years).
 
==Gross==
*Dark, shaggy, focally hemorrhagic & friable/necrotic-appearing.
*Invasive border.
 
==Microscopic==
Features:
*Two cell populations:
#'''C'''ytotrophoblasts - '''key feature'''.
#*'''C'''lear cytoplasm.
#*Polygonal shaped cells in cords/masses.
#*Distinct cell borders.
#*Single uniform nucleus.
#Syncytiotrophoblasts - may be absent.<ref>URL: [http://www.webpathology.com/image.asp?n=4&Case=36 http://www.webpathology.com/image.asp?n=4&Case=36]. Accessed on: 8 February 2011.</ref>
#*Large + many irreg. or lobular hyperchromatic nuclei.
#*Eosinophilic vacuolated cytoplasm (contains hCG).
*+/-Hemorrhage - classically in the centre of the lesion.
*+/-Necrosis.
 
Notes:
*No ''[[chorionic villi]]'' should be present.
**If chorionic villi are present... it is likely a type of [[hydatidiform mole]].
*The dual cell population may not be evident at first.
**Hemorrhage and marked nuclear pleomorphism are suggestive of the diagnosis.
 
DDx:
*[[Invasive hydatidiform mole]].
*[[Placental site trophoblastic tumour]] (PSTT).
*[[Mixed germ cell tumour]] - esp. for testicular and ovarian tumours.
 
===Images===
====Case====
<gallery>
Image: Choriocarcinoma - intermed mag.jpg | Choriocarcinoma - intermed. mag. (WC/Nephron)
Image: Choriocarcinoma - high mag.jpg | Choriocarcinoma - high mag. (WC/Nephron)
Image: Choriocarcinoma - very high mag.jpg | Choriocarcinoma - very high mag. (WC/Nephron)
Image: Choriocarcinoma -2- high mag.jpg | Choriocarcinoma - high mag. (WC/Nephron)
Image: Choriocarcinoma -2- very high mag.jpg | Choriocarcinoma - very high mag. (WC/Nephron)
</gallery>
====Case====
<gallery>
Image: Choriocarcinoma to lung -- low mag.jpg | Choriocarcinoma - low mag. (WC)
Image: Choriocarcinoma to lung -- intermed mag.jpg | Choriocarcinoma - intermed. mag. (WC)
Image: Choriocarcinoma to lung -- high mag.jpg | Choriocarcinoma - high mag. (WC)
Image: Choriocarcinoma to lung - alt -- high mag.jpg | Choriocarcinoma - high mag. (WC)
Image: Choriocarcinoma to lung -- very high mag.jpg | Choriocarcinoma - very high mag. (WC)
</gallery>
====www====
*[http://www.webpathology.com/image.asp?n=5&Case=36 Choriocarcinoma - low mag. (webpathology.com)].
*[http://www.webpathology.com/image.asp?case=36&n=1 Choriocarcinoma (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=4&Case=36 Choriocarcinoma (webpathology.com)].
*[http://chestjournal.chestpubs.org/content/138/1/220.full Choriocarcinoma (chestjournal.chestpubs.org)].<ref>{{Cite journal  | last1 = Venkatram | first1 = S. | last2 = Muppuri | first2 = S. | last3 = Niazi | first3 = M. | last4 = Fuentes | first4 = GD. | title = A 24-year-old pregnant patient with diffuse alveolar hemorrhage. | journal = Chest | volume = 138 | issue = 1 | pages = 220-3 | month = Jul | year = 2010 | doi = 10.1378/chest.09-2688 | PMID = 20605823 }}</ref>
*[http://oac.med.jhmi.edu/Pathology/Repro/Placenta/279B_Full.html Choriocarcinoma - uterus (med.jhmi.edu)].
 
==IHC==
[[ISUP]] consensus paper by Ulbright ''et al.'':<ref name=pmid24832161>{{cite journal |author=Ulbright TM, Tickoo SK, Berney DM, Srigley JR |title=Best practices recommendations in the application of immunohistochemistry in testicular tumors: report from the international society of urological pathology consensus conference |journal=Am. J. Surg. Pathol. |volume=38 |issue=8 |pages=e50–9 |year=2014 |month=August |pmid=24832161 |doi=10.1097/PAS.0000000000000233 |url=}}</ref>
*Beta-hCG +ve.
*[[Glypican 3]] +ve/-ve.
*OCT3 -ve.
*AFP -ve.
 
Others:
*p63 +ve.<ref name=pmid18318583>{{Cite journal  | last1 = Mittal | first1 = K. | last2 = Soslow | first2 = R. | last3 = McCluggage | first3 = WG. | title = Application of immunohistochemistry to gynecologic pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 3 | pages = 402-23 | month = Mar | year = 2008 | doi = 10.1043/1543-2165(2008)132[402:AOITGP]2.0.CO;2 | PMID = 18318583 }}</ref>
**[[Placental site nodule]] and [[epithelioid trophoblastic tumour]] +ve.
**[[Exaggerated placental site]] and [[placental site trophoblastic tumour]] -ve.
*Ki-67 +ve -- typically >30%.
*CK7 +ve.<ref name=pmid25469347>{{Cite journal  | last1 = Park | first1 = SY. | last2 = Lee | first2 = DE. | last3 = Park | first3 = HJ. | last4 = Kim | first4 = KC. | last5 = Kim | first5 = YH. | title = Retroperitoneal nongestational choriocarcinoma in a 25-year-old woman. | journal = Obstet Gynecol Sci | volume = 57 | issue = 6 | pages = 544-8 | month = Nov | year = 2014 | doi = 10.5468/ogs.2014.57.6.544 | PMID = 25469347 }}</ref><ref name=pmid22091297>{{Cite journal  | last1 = Hemati | first1 = S. | last2 = Esnaashari | first2 = O. | last3 = Mohajeri | first3 = M. | last4 = Sarvizadeh | first4 = M. | title = Choriocarcinoma of the breast; a case report and review of literatures. | journal = J Res Med Sci | volume = 16 | issue = 5 | pages = 707-11 | month = May | year = 2011 | doi =  | PMID = 22091297 }}</ref>
*MUC-4 +ve.<ref name=pmid18059230>{{Cite journal  | last1 = Mao | first1 = TL. | last2 = Kurman | first2 = RJ. | last3 = Huang | first3 = CC. | last4 = Lin | first4 = MC. | last5 = Shih | first5 = IeM. | title = Immunohistochemistry of choriocarcinoma: an aid in differential diagnosis and in elucidating pathogenesis. | journal = Am J Surg Pathol | volume = 31 | issue = 11 | pages = 1726-32 | month = Nov | year = 2007 | doi = 10.1097/PAS.0b013e318058a529 | PMID = 18059230 }}</ref>
*CD10 +ve (10 +ve of 10 cases<ref name=pmid19145204>{{Cite journal  | last1 = Kalhor | first1 = N. | last2 = Ramirez | first2 = PT. | last3 = Deavers | first3 = MT. | last4 = Malpica | first4 = A. | last5 = Silva | first5 = EG. | title = Immunohistochemical studies of trophoblastic tumors. | journal = Am J Surg Pathol | volume = 33 | issue = 4 | pages = 633-8 | month = Apr | year = 2009 | doi = 10.1097/PAS.0b013e318191f2eb | PMID = 19145204 }}</ref>).
 
Notes:
*Beta-hCG is classically said to be produced by syncytiotrophoblasts.<ref name=pmid20735820>{{Cite journal  | last1 = Cole | first1 = LA. | title = Biological functions of hCG and hCG-related molecules. | journal = Reprod Biol Endocrinol | volume = 8 | issue =  | pages = 102 | month =  | year = 2010 | doi = 10.1186/1477-7827-8-102 | PMID = 20735820 | PMC = 2936313 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936313/ }}</ref>
**Cytotrophoblasts also produce some<ref name=pmid20735820/><ref name=pmid12242037>{{Cite journal  | last1 = Kovalevskaya | first1 = G. | last2 = Genbacev | first2 = O. | last3 = Fisher | first3 = SJ. | last4 = Caceres | first4 = E. | last5 = O'Connor | first5 = JF. | title = Trophoblast origin of hCG isoforms: cytotrophoblasts are the primary source of choriocarcinoma-like hCG. | journal = Mol Cell Endocrinol | volume = 194 | issue = 1-2 | pages = 147-55 | month = Aug | year = 2002 | doi =  | PMID = 12242037 }}</ref> - usually no staining.
 
==See also==
*[[Germ cell tumours]].
*[[Ovarian tumours]].
*[[Gynecologic pathology]]
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Germ cell tumours]]
[[Category:Genitourinary pathology]]
[[Category:Gynecologic pathology]]
Michael
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