CASE REPORT

A Rare Case of Gestational Choriocarcinoma

Presenting as Cornual Ectopic Pregnancy
Vanessa Han, BSc, MD; Stephen Kaye, MBBCH, MD
Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC

Abstract Copyright © 2018 The Society of Obstetricians and Gynaecologists of

Canada/La Société des obstétriciens et gynécologues du Canada.
Background: Choriocarcinoma associated with cornual pregnancy is Published by Elsevier Inc. All rights reserved.
extremely rare. To our knowledge, only three other cases have
been reported in the literature.
Case: A 38-year-old woman was found to have a left cornual ectopic J Obstet Gynaecol Can 2018;40(3):351–353
pregnancy on ultrasound after presenting with abdominal pain, https://doi.org/10.1016/j.jogc.2017.08.009
irregular vaginal bleeding, and a positive pregnancy test.
Laparoscopy confirmed the diagnosis and she underwent total
abdominal hysterectomy. Three weeks later, she presented with
vaginal bleeding. A solid ulcerating lesion was found arising from
INTRODUCTION
the vaginal wall and biopsy revealed metastatic gestational
choriocarcinoma.
Conclusion: Careful histopathological examination of the surgical
specimen and diligent monitoring of β-human chorionic
C horiocarcinoma associated with ectopic pregnancy is
very rare, with an estimated incidence of less than 1.5
per 1 million births.1 This extremely aggressive gestational
gonadotropin to zero is crucial to prevent potentially missing this trophoblastic neoplasm (GTN) is most commonly due to
very malignant, but highly curable disease. Early systemic malignant transformation of a molar pregnancy, but can
metastases are common and presentation can include bleeding
from vaginal metastases. develop after all types of pregnancy. We report a new case
of choriocarcinoma arising in a cornual pregnancy. To our
Résumé knowledge, only three cases of cornual pregnancy associ-
ated with choriocarcinoma have been reported in the
Contexte : Les choriocarcinomes associés aux grossesses
cornuales sont extrêmement rares. À notre connaissance, la literature.2–4
littérature ne fait état que de trois autres cas.
Cas : Une femme de 38 ans ayant obtenu un résultat positif à un test
THE CASE
de grossesse s’est présentée en consultation en raison de
douleurs abdominales et de saignements vaginaux irréguliers.
Une échographie a révélé la présence d’une grossesse extra-
A 38-year-old woman, G5T2A2E1L2, presented with a six-
utérine dans la corne gauche, diagnostic qui a ensuite été day history of lower abdominal pain. She reported last
confirmé par laparoscopie. La patiente a subi une hystérectomie menstrual period 21 days prior. Serum β-human chorionic
abdominale totale. Trois semaines plus tard, elle présentait des
gonadotropin (β-hCG) was 78 465 IU/L and hemoglobin
saignements vaginaux. Une lésion ulcéreuse dure située dans la
paroi vaginale a été découverte; une biopsie a montré qu’il was 125 g/L. Ultrasonography revealed no intrauterine preg-
s’agissait d’un choriocarcinome gestationnel métastatique. nancy and a 5.6 cm mass in the left cornua with peripheral
Conclusion : L’examen histopathologique minutieux de l’échantillon hypervascularity and subserosal hemorrhage extending along
chirurgical et le suivi attentif du retour du taux de the left lateral fundus. There was no fetal pole identified and
β-gonadotrophine chorionique humaine à zéro sont essentiels
no pelvic free fluid. The adnexa were normal.
pour éviter que cette maladie très maligne, mais facilement
curable, ne passe inaperçue. Les métastases systémiques
précoces sont courantes, et les symptômes peuvent comprendre Medical history included one presumed ectopic pregnancy
le saignement des métastases vaginales. 8 months prior, which was treated at another centre with
suction curettage and one dose of intramuscular metho-
Key Words: Cornual pregnancy, interstitial pregnancy, ectopic,
choriocarcinoma
trexate. β-hCG level subsequently declined but was not
followed to zero. The patient was prescribed a transder-
Corresponding Author: Dr. Vanessa Han, Department of
Obstetrics and Gynecology, University of British Columbia, mal contraceptive patch and resumed regular menstrual
Vancouver, BC. vanessa.han@alumni.ubc.ca cycles. Her general health was unremarkable.
Competing interests: None declared.
On examination, the patient was stable. The abdomen was
Received on July 11, 2017
soft with mild left lower quadrant discomfort and no rebound
Accepted on August 10, 2017
tenderness. The patient received one dose of intramuscular

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CASE REPORT
Figure 1. Intraoperative view of left cornual mass with tissue
distorting the serosal surface.
methotrexate methotrexate (50 mg/m2) and was moni-
tored as an inpatient. She began to have some vaginal
bleeding and β-hCG decreased but then plateaued at
62 209 IU/L. A decision was made to perform a laparos-
copy to confirm the diagnosis of cornual ectopic pregnancy
and proceed with definitive surgical management as the
patient did not desire future fertility.
On laparoscopy, a large mass was visualized distorting the left
cornua with hemorrhagic tissue penetrating through the myo-
metrium, elevating the serosa from the normal contour
(Figures 1 and 2). Open total abdominal hysterectomy with bi-
lateral salpingectomy was performed without complication and
the patient was discharged home on postoperative day 3. Pa-
thology was consistent with cornual ectopic pregnancy.
The patient returned 3 weeks later with increased vaginal
bleeding. Serum β-hCG was 571 IU/L. Speculum exami-
nation demonstrated an intact vaginal vault and a firm
ulcerating mass arising from the left lateral vaginal wall.
Biopsy showed hemorrhagic tissue composed of large
atypical cells strongly positive for β-hCG. Pathology
review confirmed diagnosis of metastatic gestational
choriocarcinoma.
The patient was admitted to the Medical Oncology Unit and
CT imaging revealed multiple pulmonary metastases, but no
intracranial or intra-abdominal metastases. The patient was
categorized as high risk with a WHO score of 8 and was
treated with multi-agent etoposide, methotrexate, actino-
mycin D, cyclophosphamide, and vincristine/oncovin
chemotherapy.
DISCUSSION
An estimated 0.76% to 4% of choriocarcinomas arise from
an ectopic pregnancy.5,6 Early systemic metastases to the
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Figure 2. Bisected hysterectomy speci-
men showing hemorrhagic cornual mass.
vagina, lung, liver, and brain are common.7 Fortunately cho-
riocarcinoma, including those arising in an ectopic location,
is highly responsive to chemotherapy, and prognosis is ex-
cellent even in advanced stages.7,8
Diagnosis of ectopic GTN is challenging because the clini-
cal symptoms are non-specific and presentation is often not
distinguishable from typical tubal pregnancies.1,5,8 Sonography,
colour-flow Doppler, MRI, and hysteroscopy have been used
in the diagnosis of ectopic GTN; however, sensitivity is low
and the diagnosis is often incidental on postoperative his-
tological examination.9,10 The typical sonographic appearance
of choriocarcinoma is an echogenic irregular hypervascular
mass occupying the uterine cavity. Specific findings for extra-
uterine choriocarcinoma have not been established.4
Location in the cornua may further complicate diagnosis and
management of GTN. Only three other women with cho-
riocarcinoma arising in the cornua have been previously
reported in the literature (Table). Review of the published
cases reveals the challenges of diagnosing cornual chorio-
carcinoma. In two cases, the tumour was misdiagnosed as
myoma on preoperative imaging and diagnostic laparoscopy.2,3
In the case described by Meddeb et al., choriocarcinoma was
not diagnosed until after a second histopathologic speci-
men was examined, similar to our case.4 Histological diagnosis
of ectopic GTN is difficult, and expert review should occur
in cases where there is clinical or histological suspicion.9 Mis-
diagnosis can occur due to its rarity, lack of distinguishing
clinical features, poor tissue sample available for
 A Rare Case of Gestational Choriocarcinoma Presenting as Cornual Ectopic Pregnancy

histological examination, and lack of discriminating

No metastases. 3 cycles MTX

POD#25. No metastases. 1

POD#7. No metastases. 1
cycle MTX chemotherapy

cycle MTX chemotherapy

immunohistochemistry.11

metastases. EMA-CO
β-hCG undetectable by

β-hCG undetectable by

Pulmonary and vaginal

Outcome

β-hCG: β-human chorionic gonadotropin; D+C: dilatation and curettage; EMA-CO: etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine/oncovin; MTX: methotrexate; US: ultrasound.
CONCLUSION

chemotherapy

chemotherapy
This case highlights the importance of careful histopathologi-
cal examination of the surgical specimen in every patient
presenting with ectopic pregnancy, including those located in
the cornua. Regardless of medical or surgical management, dili-
gent monitoring of β-hCG to zero is crucial in all cases of

2. Laparotomy, hysterectomy
2. Laparotomy, cornuotomy

Laparoscopy, converted to
suspected ectopic pregnancy to prevent potentially missing
3. Laparoscopy, cornual

1. Laparoscopy, cornual
Surgical treatment

GTN. Choriocarcinoma is rare, very malignant, but highly

open hysterectomy
1. Laparoscopy, D+C

curable. Early systemic metastases are common, and presen-

2. Hysteroscopy

tation can include bleeding from vaginal metastases.

resection

resection
1. D+C

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1

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