PDF 
Views 
Share
A Case Series of Gestational Choriocarcinoma with Review of Literature
CC BY 4.0 · Indian J Med Paediatr Oncol 2024; 45(04): 357-362
DOI: DOI: 10.1055/s-0043-1771180
Abstract
Choriocarcinoma can be gestational and nongestational. Gestational choriocarcinoma is rare with an incidence of 9.2 in 40,000 pregnancies in Asian population. They can occur following molar, partial molar pregnancy, abortion, or delivery. It is detected by elevated levels of serum beta-human chorionic gonadotropin (beta-hCG) and by imaging modality. The need for histopathological diagnosis for choriocarcinoma is debatable. Six cases of choriocarcinoma are described with variable presentations and outcomes. Out of six cases, three were following vaginal delivery, two were after abortion, and one case was perimenopausal with antecedent pregnancy 10 years ago, unclear whether it was the cause for choriocarcinoma. Brain and lung metastasis were seen in three cases each; one case, which had metastasis to all organs, had worse prognosis and succumbed to the disease. All belonged to high-risk group according to International Federation of Gynaecology and Obstetrics score (8–13). The prognosis is usually very good, provided that prompt diagnosis and treatment are initiated early. Long-term follow-up with beta-hCG levels needs to be done to detect recurrence but it did not act like a prognostic indicator in our case series.
Keywords
choriocarcinoma - gestational trophoblastic neoplasia - metastasisAuthors' Contributions
All authors have agreed for the manuscript description. AT contributed to data collection and manuscript preparation. VS contributed to concept design and clinical treatment. NN contributed to manuscript preparation and editing.
Patient's Consent
Informed consent was obtained from all individual participants included in the study.
Publication History
Article published online:
22 September 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
Abstract
Choriocarcinoma can be gestational and nongestational. Gestational choriocarcinoma is rare with an incidence of 9.2 in 40,000 pregnancies in Asian population. They can occur following molar, partial molar pregnancy, abortion, or delivery. It is detected by elevated levels of serum beta-human chorionic gonadotropin (beta-hCG) and by imaging modality. The need for histopathological diagnosis for choriocarcinoma is debatable. Six cases of choriocarcinoma are described with variable presentations and outcomes. Out of six cases, three were following vaginal delivery, two were after abortion, and one case was perimenopausal with antecedent pregnancy 10 years ago, unclear whether it was the cause for choriocarcinoma. Brain and lung metastasis were seen in three cases each; one case, which had metastasis to all organs, had worse prognosis and succumbed to the disease. All belonged to high-risk group according to International Federation of Gynaecology and Obstetrics score (8–13). The prognosis is usually very good, provided that prompt diagnosis and treatment are initiated early. Long-term follow-up with beta-hCG levels needs to be done to detect recurrence but it did not act like a prognostic indicator in our case series.
Keywords
choriocarcinoma - gestational trophoblastic neoplasia - metastasisIntroduction
Choriocarcinoma is a subtype of gestational trophoblastic neoplasia (GTN), an extremely malignant tumor. GTN also includes invasive mole, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). Choriocarcinoma and molar pregnancy arise from cytotrophoblasts and syncytiotrophoblasts, whereas PSTT and ETT arise from intermediate trophoblasts.[1] It produces human chorionic gonadotropin(hCG) and is highly vascular.[2] Gestational choriocarcinoma is a rare malignancy with an incidence of 9.2 in 40,000 pregnant women in southeast Asia.[3] GTN can be distinguished into nonmetastatic and metastatic. Lesions that are limited to the uterus are termed nonmetastatic GTN. Lesions outside the uterus that spread typically through hematogenous dissemination are termed metastatic GTN.[4] Most common site of metastasis is lung, followed by vagina, brain, liver, and intestines.[4] Early diagnosis of gestational choriocarcinoma is crucial as it is highly chemosensitive and has an excellent prognosis, even in advanced stages.[3] This case series demonstrates different scenarios of choriocarcinoma. Here, we would like to share six cases of choriocarcinoma in the last 5 years in our hospital ([Table 1]).
|
No. |
Age (y) |
Clinical presentation |
Antecedent pregnancy |
Interval (mons) |
Beta-hCG (mIU/mL) |
Sites of metastasis |
FIGO score |
Treatment |
Outcome |
|---|---|---|---|---|---|---|---|---|---|
|
1 |
24 |
Postpartum persistent vaginal bleeding, altered sensorium, slurred speech |
Vaginal delivery |
2 |
1,08,000 |
Brain |
12 |
6 cycles of EMACO Brain radiation |
In remission; no relapse |
|
2 |
32 |
Generalized weakness |
Missed abortion (HPR—NA) |
2 |
34,900 |
All organ metastasis |
12 |
Ongoing 1st cycle of EMACO |
Died |
|
3 |
31 |
Lower abdominal pain |
Incomplete abortion (HPR—NA) |
3 |
5,872 |
Brain, lungs |
12 |
2 cycles of EMACO; developed respiratory complication; discontinued treatment |
Lost to follow-up |
|
4 |
28 |
Pain abdomen, irregular vaginal bleeding |
Vaginal delivery |
13 |
68,000 |
Nil |
8 |
6 cycles of EMACO |
In remission; no relapse |
|
5 |
52 |
Pain abdomen, generalized weakness |
Vaginal delivery |
120 |
2,26,150 |
Nil |
13 |
6 cycles of EMACO followed by TAH + BSO |
In remission; no relapse |
|
6 |
32 |
Pain abdomen, amenorrhea |
Vaginal delivery |
18 |
8,49,850 |
Lungs |
12 |
Still under treatment. Received 2nd cycle of EMACO |
– |
Fig.1:Computed tomography brain showing an intraparenchymal lesion in left frontoparietal region.
Her International Federation of Gynaecology and Obstetrics (FIGO) score was 12 (high risk: <40 delivery = 2), months = 0), mL = 4),>5cm = 2), metastasis (brain = 4), number of metastasis (two = 1), and previous failed chemotherapy drugs (no = 0).
She received six cycles of chemotherapy with etoposide, methotrexate, actinomycin-D, cyclophosphamide, oncovin (EMACO) followed by cranial radiation therapy of 20 fractions. Post-treatment beta-hCG dropped to 5.13mIU/mL. Presently she has minimal right upper limb weakness and is on follow-up for the last 4 years.
Case 3
A 31-year-old lady, G3A2, had undergone suction evacuation for incomplete abortion 2 months ago outside hospital. HPR was not available. She came to our center with 2 months of amenorrhea, lower abdominal pain, and excessive vomiting. Her beta-hCG was 5,872mIU/mL. Ultrasound abdomen showed an enlarged uterus with a heterogenous mass (>5cm) lesion within the endometrial cavity, infiltrating the myometrium, suggestive of GTN. CECT chest was suggestive of lung metastasis. MRI head showed hemorrhagic vascular periventricular deposits in the right corona radiata involving the choroid plexus of the bilateral lateral ventricle, third and fourth ventricle (brain metastasis).
Her FIGO score was 12 (high risk): less than 40 years old (31 = 0), index pregnancy (abortion = 1), time since delivery (<4 months = 0), mL = 1), cm = 2), brain = 4),>8 = 4), and previously failed chemotherapy drugs (no = 0).
She was planned for six cycles of EMACO regimen and cranial radiation. She received two cycles of chemotherapy; later she developed complaints of breathlessness, hypotension and was diagnosed to have pulmonary edema. The patient and family discontinued the treatment in view of financial constraints and were lost to follow-up.
Case 4
A multiparous (P5L5) lady of 28 years presented to a hospital outside with 2 months duration of pain abdomen and irregular heavy menstrual bleeding. All were normal vaginal deliveries; last childbirth was 1 year ago. After dilatation and curettage, medical management for abnormal uterine bleeding was tried, but her symptoms were not relieved. Finally, they did a total abdominal hysterectomy with bilateral salpingectomy in that hospital. HPR showed features of choriocarcinoma (<3>
Her FIGO score was 8 (high risk): less than 40 years old (28 = 0), index pregnancy (term = 2), time since delivery (>12 months = 4), beta-hCG (68,000mIU/mL = 2), size of the tumor (<3 cm = 0), no = 0), no = 0).>
She received six cycles of chemotherapy with EMACO. Post-chemotherapy beta-hCG was 3.13mIU/mL. She is being followed up for the past 2 years and is doing fine.
Case 5
A 54-year-old perimenopausal woman, P6L6, presented to our hospital with lower abdominal pain. She had lost weight and experienced easy fatigability. Her last menstrual period was 6 months ago. Her previous cycles were normal. She had all vaginal deliveries, with no history of GTN and her last delivery was 10 years ago. On admission, she was pale and tachycardic, and systemic examination was normal. Uterine fundus was 12 weeks enlarged. Ultrasound abdomen revealed large hyperechoic heterogeneous lesion with cystic changes that measure 6.2 × 5.8cm, with no vascularity and no lesions in the liver and lungs. Beta-hCG was 2,26,150mIU/mL. Chest X-ray and MRI brain were normal.
Her FIGO score was 13 (high risk): more than40 years old (52 = 1), index pregnancy (term = 2), time since delivery (10 years = 4), beta-hCG (2,26,150mIU/mL = 4), size of the tumor (>5 cm = 2), metastasis (no = 0), and previously failed chemotherapy drugs (no = 0).
She received six cycles of chemotherapy with EMACO regimen. Beta-hCG levels dropped to 1.40 mIU/mL. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient is in good health and is being followed up in our center for the last 4 years.
A, P2L2A1, 32-year-old lady presented with complaints of pain abdomen and amenorrhea for 2 months. Scan abdomen showed uterine mass and serum beta-hCG was 8,49,850mIU/mL. She had delivered her second child 1½ years ago by normal vaginal delivery. Prior to this she had a molar pregnancy that was evacuated and followed by beta-hCG levels. MRI abdomen and pelvis ([Fig. 2]) showed a well-defined multilobulated lesion measuring 10 × 10 × 12cms, arising from the fundus and posterior myometrium. CT chest showed multiple parenchymal lung nodular metastatic lesions. MRI brain was normal.
Fig.2:Magnetic resonance imaging of pelvis showing multilobulated lesion of 10 × 10 × 12cm arising from the fundus and posterior myometrium.
Her FIGO score was 12 (high risk): less than 40 years old (32 = 0), index pregnancy (term = 2), time since delivery (>12 months = 4), beta-hCG (8,49,850 mIU/mL = 4), size of the tumor (>5cm = 2), metastasis (lung = 0), and previously failed chemotherapy drugs (n = 0).
She is planned for six cycles of chemotherapy with EMACO. She has received two cycles of chemotherapy and currently under treatment.
Discussion
GTN
is most commonly seen in reproductive age women. It is seen in 9.2 and 3.3 in
40,000 pregnant women in southeast Asia and Japan, respectively[3] and much rarer, that is 1 in 50,000
deliveries in United States of America.[2] It can occur after any antecedent
pregnancy. It usually occurs 50%- of cases after hydatidiform mole, 25%- cases
after spontaneous abortion, 22.5%- after normal pregnancy, and 2.5%- after
ectopic gestation.[5] In our case series, out of six cases, three
cases were after vaginal delivery that is difficult to diagnose as they present
with abnormal uterine bleeding (either amenorrhea, irregular vaginal bleeding
or persistent vaginal bleeding) and present to the hospital late. Two cases
were after abortion where products were not sent for HPR, so it might have been
a type of molar pregnancy that needed follow-up. It is extremely important to
send the products for HPR. The case in perimenopausal age was nearly 10 years
after her last pregnancy, so one cannot be sure what triggered the
choriocarcinoma, whether it was the antecedent pregnancy or did it happen de
novo. In such cases, it is difficult to say whether the antecedent pregnancy
led to choriocarcinoma.[5]
Choriocarcinoma
after nonmolar pregnancy is associated with worse outcomes due to delay in
diagnosis and widespread metastatic disease, increased interval between onset
of disease, and previous pregnancy.[6] In our case series, all were after nonmolar
pregnancies and in that four had metastatic disease. So, high level of
suspicion and prompt diagnosis and appropriate treatment with chemotherapy can
save lives and will have very good prognosis. Choriocarcinoma can clinically
present with abnormal uterine bleeding, acute pelvic pain, and metastatic
symptoms such as chest pain, cough, hemoptysis, dyspnea, epigastric pain,
neurological deficits secondary to brain hemorrhage. GTN is further classified
into metastatic and nonmetastatic disease. Nonmetastatic disease occurs in 15%-
of cases and metastatic disease in 4%- of cases after complete mole evacuation.
Metastatic disease is more often seen after nonmolar gestation.[7] Metastasis is most commonly to lungs 60 to
75%-, vagina 40 to 50%-, brain and liver 15 to 20%-, spleen, central nervous
system and intestines 10%-, very rarely manifests as cardiac metastasis. In 30%-
cases, by the time of final diagnosis, metastasis would have already occurred.[5] In our case series, brain metastasis was
seen in three cases, lung metastasis was seen in three cases, one case had
multiorgan metastasis that had worse prognosis and succumbed to the disease,
and two cases had no metastasis.
Initial
diagnosis is made based on clinical features, serum beta-hCG, and pelvic
imaging such as ultrasound and MRI. Beta-hCG is an excellent marker for
diagnosis. First line of imaging is color Doppler USG, used to look for uterine
cavity and vascularity. Choriocarcinoma is characterized by myometrial and
vascular invasion.[8] As diagnostic adjuvants, CT or MRI can be
used to assess depth of myometrial invasion and extrauterine spread. Chest
radiography, high-resolution CT chest, and MRI brain are used to stage the
disease.[5] Diagnosis is confirmed after
histopathological examination of endometrial curetting or the placenta. The
true incidence of choriocarcinoma may be higher than the reported data, likely
due to missed cases as half of the cases are asymptomatic and routine
pathological examination of placenta is not performed.[8]
The
World Health Organization (WHO) prognostic scoring system is used for plan of
management. If it is low risk (score < 6), single
agent chemotherapy is given. If it is a high risk (score > 7),
multidrug chemotherapy with or without surgery/ radiation therapy is the line
of management. Beta-hCG is an excellent surveillance marker for choriocarcinoma
but is not a prognostic indicator as in our series we found patients with low
beta-hCG performed poorly. Five-year survival rate can be up to 90%-.[2] GTN is a rare human tumor that can be cured
even in the presence of widespread dissemination.[7] In all our cases, FIGO score ranged from 8
to 13, belonged to high-risk group. EMACO was the first line of choice for
multidrug chemotherapy in our cases. One patient died and one lost to
follow-up, one patient is currently under treatment, and other cases are under
remission. Our patients who completed the treatment achieved undetectable
beta-hCG levels after four cycles and went on to receive two more cycles of
consolidation chemotherapy. The need for increased methotrexate dose was not
required in our case 1 who had brain metastasis as she responded well to
regular EMACO regimen and she also received brain radiation. In patients with
brain metastases, an increase in the methotrexate infusion to 1g/m2 will
help the drug cross the blood–brain barrier better and is found to be
beneficial. Some centers also use intrathecal methotrexate of 12.5 mg.[9] This can be given at the time of CO when
EMACO is used, or with the EP in the etoposide, methotrexate, actinomycin-D,
etoposide, cisplatin (EMA/ EP) regimen. Some may give whole brain radiotherapy
3000 cGy in 200cGy daily fractions concurrent with chemotherapy or use
stereotactic or gamma knife radiation to treat existing or residual brain
metastases after chemotherapy.[9]
Recurrence
rate of conventional low-risk GTN is 1.6 to 3.1%- and high-risk is 6.9%-.[4] Even in cases of recurrence, a good cure
rate has been observed with the use of etoposide and platinum drugs, combined
with surgical excision of drug-resistant lesions and radiation therapy. For
patients failing to respond to regular EMACO regimen, multiple salvage
therapies are also available. Other chemotherapy regimens include TP/TE
(paclitaxel and cisplatin interchanged with paclitaxel and etoposide weekly),
BEP (bleomycin, etoposide, cisplatin), VIP (etoposide, ifosfamide, cisplatin),
and ICE (ifosfamide, carboplatin, etoposide). Role of peripheral blood stem
cell support and high-dose chemotherapy is uncertain. Role of immunotherapy in
the management needs further investigation. The fact that GTN strongly
expresses Programmed Death - Ligand 1 (PD-L1) has led to checkpoint inhibitor
use in GTN, a significant advance of immunotherapy in recent years.
Pembrolizumab (anti-PD-L1) has effectively induced complete responses in 75 to
80%- of unresectable, chemo-resistant GTN, including cases that had failed high
dose chemotherapy.[4]
In
a case series of six cases, patients displayed a variety of unusual clinical
manifestation including suspected pulmonary tuberculosis, lung mass, pneumonia,
heavy vaginal bleeding, pelvic mass, and peritonitis that highlighted the
importance of having a high degree of clinical suspicion of choriocarcinoma in
women of reproductive age.[10] All their cases were with scores of 8 to
12, EMACO therapy and selective hysterectomy proved to be beneficial.
Administering three cycles of consolidation chemotherapy after remission that
is given every 15 days was their standard practice.
In
a systematic review,[11] a total of 121 case reports pertaining to
unusual clinical manifestations of gestational choriocarcinoma were analyzed.
The age of patients reported ranged from 17 to 67 years, and the time period
between the index pregnancy and development of choriocarcinoma varied from 4
weeks to as long as 25 years. This shows choriocarcinoma can occur in any age
(even menopause) and several years after the antecedent pregnancy just like in
our case 5 where diagnosing the disease becomes challenging. Cardiopulmonary
complaints (20.66%-) followed by gastrointestinal (18.43%-) and central nervous
system manifestations (17.67%-) were found to be the most common.[11]
Though
hematogenous metastasis is well known in choriocarcinoma that spreads to lung
initially and liver is the most common organ to metastasize in the abdomen,
authors noted intestine metastasis in 5%- cases in their case series.[12] They recommended a comprehensive
evaluation including whole abdomen CT for all patients, not only those with
pulmonary metastases. Intestinal metastasis has a poor prognosis.
For those patients with widespread metastasis, starting with standard chemotherapy may cause sudden tumor collapse with severe bleeding, metabolic acidosis, myelosuppression, septicemia, and multiple organ failure, any or all of which can result in early death that may have been the reason in our case 2 as she had extensive metastasis and succumbed to the disease during first cycle of EMACO regimen. To avoid this, the use of initial gentle rather than full-dose chemotherapy has been suggested. Induction with etoposide 100 mg/m2 and cisplatin 20 mg/m2 on days 1 and 2, repeated weekly for 1 to 3 weeks, before starting normal chemotherapy appears to have eliminated early deaths in one series[13] and similar promising results were reported by others too.[14]
Conclusion
Conflict of Interest
None declared.
Authors' Contributions
All authors have agreed for the manuscript description. AT contributed to data collection and manuscript preparation. VS contributed to concept design and clinical treatment. NN contributed to manuscript preparation and editing.
Patient's Consent
Informed consent was obtained from all individual participants included in the study.
References
- AlJulaih GH, Muzio MR. Gestational Trophoblastic Neoplasia. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Jan. Accessed July 02, 2023 at https://www.ncbi.nlm.nih.gov/books/NBK562225/
- Romeo DA, Gutman DA, Sirianni J, Marotta M. A diagnosis of choriocarcinoma in a parturient presenting with intracranial haemorrhage. J Med Cases 2022; 13 (04) 151-154
- Gupta S, Jhirwal M, Sharma C, Shekhar S. A rare case of gestational choriocarcinoma with lung and vaginal metastasis with obstructive jaundice. J Obstet Gynaecol India 2022; 72 (03) 262-264
- Li J, Wang Y, Lu B, Lu W, Xie X, Shen Y. Gestational trophoblastic neoplasia with extrauterine metastasis but lacked uterine primary lesions: a single center experience and literature review. BMC Cancer 2022; 22 (01) 509
- Kyejo W, Rubagumya D, Ntiyakuze G. et al. Diagnostic challenge of perimenopause molar pregnancy in a 52-year-old lady: case report. Int J Surg Case Rep 2022; 99: 107648
- Berkowitz RS, Horowitz NS, Goldstein DP. Gestational trophoblastic disease. In: Berek JS. ed. Berek and Novak's gynecology, 16th ed. Philadelphia: Wolters Kluwer; 2020: 2507-2509
- Katsanevakis E, Oatham A, Mathew D. Choriocarcinoma after full-term pregnancy: a case report and review of the literature. Cureus 2022; 14 (02) e22200
- Zhong L, Yin R, Song L. Post-partum choriocarcinoma mimicking retained adherent placental remnants: a rare case report. Heliyon 2022; 8 (10) e11105
- Ngan HYS, Seckl MJ, Berkowitz RS. et al. Update on the diagnosis and management of gestational trophoblastic disease. Int J Gynaecol Obstet 2018; 143 (Suppl. 02) 79-85
- Tamang T, Tshomo U. Gestational choriocarcinoma with varied clinical presentation and treatment outcome: a case series. J South Asian Feder Obst Gynae 2018; 10 (04) 276-280
- Mangla M, Singla D, Kaur H, Sharma S. Unusual clinical presentations of choriocarcinoma: a systematic review of case reports. Taiwan J Obstet Gynecol 2017; 56 (01) 1-8
- Wang Y, Wang Z, Zhu X. et al. Intestinal metastasis from choriocarcinoma: a case series and literature review. World J Surg Oncol 2022; 20 (01) 173
- Alifrangis C, Agarwal R, Short D. et al. EMA/CO for high-risk gestational trophoblastic neoplasia: good outcomes with induction low-dose etoposide-cisplatin and genetic analysis. J Clin Oncol 2013; 31 (02) 280-286
- Bolze PA, Riedl C, Massardier J. et al. Mortality rate of gestational trophoblastic neoplasia with a FIGO score of ≥13. Am J Obstet Gynecol 2016; 214 (03) 390.e1-390.e8
Address for correspondence
Publication History
Article published online:
22 September 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
References
- AlJulaih GH, Muzio MR. Gestational Trophoblastic Neoplasia. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Jan. Accessed July 02, 2023 at https://www.ncbi.nlm.nih.gov/books/NBK562225/
- Romeo DA, Gutman DA, Sirianni J, Marotta M. A diagnosis of choriocarcinoma in a parturient presenting with intracranial haemorrhage. J Med Cases 2022; 13 (04) 151-154
- Gupta S, Jhirwal M, Sharma C, Shekhar S. A rare case of gestational choriocarcinoma with lung and vaginal metastasis with obstructive jaundice. J Obstet Gynaecol India 2022; 72 (03) 262-264
- Li J, Wang Y, Lu B, Lu W, Xie X, Shen Y. Gestational trophoblastic neoplasia with extrauterine metastasis but lacked uterine primary lesions: a single center experience and literature review. BMC Cancer 2022; 22 (01) 509
- Kyejo W, Rubagumya D, Ntiyakuze G. et al. Diagnostic challenge of perimenopause molar pregnancy in a 52-year-old lady: case report. Int J Surg Case Rep 2022; 99: 107648
- Berkowitz RS, Horowitz NS, Goldstein DP. Gestational trophoblastic disease. In: Berek JS. ed. Berek and Novak's gynecology, 16th ed. Philadelphia: Wolters Kluwer; 2020: 2507-2509
- Katsanevakis E, Oatham A, Mathew D. Choriocarcinoma after full-term pregnancy: a case report and review of the literature. Cureus 2022; 14 (02) e22200
- Zhong L, Yin R, Song L. Post-partum choriocarcinoma mimicking retained adherent placental remnants: a rare case report. Heliyon 2022; 8 (10) e11105
- Ngan HYS, Seckl MJ, Berkowitz RS. et al. Update on the diagnosis and management of gestational trophoblastic disease. Int J Gynaecol Obstet 2018; 143 (Suppl. 02) 79-85
- Tamang T, Tshomo U. Gestational choriocarcinoma with varied clinical presentation and treatment outcome: a case series. J South Asian Feder Obst Gynae 2018; 10 (04) 276-280
- Mangla M, Singla D, Kaur H, Sharma S. Unusual clinical presentations of choriocarcinoma: a systematic review of case reports. Taiwan J Obstet Gynecol 2017; 56 (01) 1-8
- Wang Y, Wang Z, Zhu X. et al. Intestinal metastasis from choriocarcinoma: a case series and literature review. World J Surg Oncol 2022; 20 (01) 173
- Alifrangis C, Agarwal R, Short D. et al. EMA/CO for high-risk gestational trophoblastic neoplasia: good outcomes with induction low-dose etoposide-cisplatin and genetic analysis. J Clin Oncol 2013; 31 (02) 280-286
- Bolze PA, Riedl C, Massardier J. et al. Mortality rate of gestational trophoblastic neoplasia with a FIGO score of ≥13. Am J Obstet Gynecol 2016; 214 (03) 390.e1-390.e8