Open Access

A gestational choriocarcinoma of the ovary diagnosed by DNA polymorphic analysis: a case report and systematic review of the literature

Journal of Ovarian Research201710:46

https://doi.org/10.1186/s13048-017-0334-3

Received: 22 February 2017

Accepted: 23 May 2017

Published: 20 July 2017

Abstract

Background

Choriocarcinoma of the ovary is rare. This tumor can arise from gestational tissue or pure germ cells of the ovary, the former results in gestational choriocarcinoma. The clinical characteristics and histology of both tumor types are identical, differentiation of these tumors is necessary for effective treatment. One strategy for the differentiation of these tumors types is to identify the presence of paternal DNA by DNA polymorphic analysis.

Case presentation

In the present case, a 27-year-old patient with a history of amenorrhea, lower abdominal pain and vaginal bleeding received a laparoscopic dissection of cystic mass of the right ovary according to an initial diagnosis of ectopic pregnancy. Primary choriocarcinoma of the ovary was diagnosed by pathology, but its origin was uncertain. DNA polymorphic analysis was then performed and a gestational origin was confirmed. The patient subsequently exhibited an excellent response to chemotherapy, achieved complete remission and gave birth to a healthy baby.

Conclusion

Differentiation between two etiologies of primary choriocarcinoma can be achieved with DNA polymorphic analysis and it is necessary to distinguish between them to approach to an appropriate treatment of a patient.

Keywords

Gestational choriocarcinoma of the ovary DNA polymorphic analysis

Background

Primary choriocarcinoma of the ovary can arise from gestational tissue or pure germ cells of the ovary. They are referred to as gestational choriocarcinoma (GCO) or non-gestational choriocarcinoma (NGCO). The estimated incidence of GCO of the ovary is 1:369,000,000 pregnancies, while non-gestational choriocarcinomas correspond to less than 0.6% of ovarian germ cell tumors [1, 2], making this neoplasm very rare. Moreover, both gestational and non-gestational diseases exhibit identical clinical manifestations and histology. The clinical history of pregnancy, amenorrhea, or gestational trophoblastic disease may help to determine the diagnosis, but difficult cases often need DNA analysis, which has not often been performed in the previous reported cases. Saito et al. first described the diagnostic criteria for NGCO in 1963. These include absence of disease in the uterine cavity, pathological confirmation of disease, and exclusion of molar pregnancy and of intrauterine pregnancy [3]. All the criteria were fulfilled in this case, but the presence of paternal DNA revealed the final diagnosis of GCO, indicating that clinical diagnostic criteria are not reliable, except in patients who are unable to conceive or who have never had sexual intercourse [4]. These tumor types should be considered distinct entities with distinct therapeutic approaches, chemotherapy regimens, and prognosis associated with each disease. We summarized 48 cases (ours included) of primary ovarian choriocarcinoma published since 1982. Sixteen more cases reported from 1937 to 1982 are not listed in this article. Although most of the authors declared the reported cases were NGCO, we reanalyzed the information and only 24 NGCO and 2 GCO could be confirmed.

Case presentation

A 27-year-old married woman (gravida 0) was admitted to a local hospital with a history of 51 days of amenorrhea, lower abdominal pain and vaginal bleeding for 5 days. Her previous menstrual cycles were regular. Her medical history and family history were unremarkable. The general condition of the patient appeared to be good, and pelvic examination revealed a mass in the right adnexal area with tenderness. The urine test showed she was pregnant, and serum β-hCG level was more than 200,000 mIU/ml. Transvaginal ultrasound (TVS) revealed a right adnexal mass and profuse abdominal fluid accumulation.

According to an initial diagnosis of ectopic pregnancy, laparoscopic exploration was performed. The right ovary was 5*6 cm, partially cystic, ruptured and surrounded by a hematoma. The left ovary and both fallopian tubes were intact. Approximately 500 ml of intraperitoneal blood was noted. The cystic mass of the right ovary was dissected and sent to pathological diagnosis. On the fifth postoperative day, serum β-hCG levels was 14,510 mIU/ml. The patient then transferred to our hospital six days after the surgery. The pathological consult confirmed a pure choriocarcinoma of the right ovary, and an immunohistochemical panel was performed and the samples analyzed were positive for Pan Cytokeratin (AE1/AE3), hCG, human placental lactogen (hPL) and Ki-67(60%), and negative for p53. (Fig. 1).
Fig. 1

The tumor consists of two types of trophoblastic cells without villus, so choriocarcinoma was diagnosed. SC: syncytiotrophoblastic cells; CC: cytotrophoblastic cells; EC: vascular epithelial cells

At the 7th and 10th postoperative day, the serum β-hCG levels fell to 5907 and 2000 mIU/ml, respectively. Further imaging examination was proceeded ten days after the surgery. The contrast pelvic MRI showed the right ovary was 2.1*2.9*3.2 cm, at the front of which a mass of 1.2 cm*1.0 cm was observed. PET-CT showed bilateral ovarian nodules with hypermetabolism, physiological uptake considered, no other specific abnormalities were observed. Other related tests were examined: CA125 (cancer antigen 125): 70.81 U/ml, AFP (alpha fetoprotein): 2.28 ng/ml. As the endometrium thickness was only 5 mm, endometrial biopsy had not been performed.

The patient received five courses of EP-EMA chemotherapy, including cisplatin (80 mg/m2) and etoposide (100 mg/m2), D1; etoposide (100 mg/m2), methotrexate (100 mg/m2 iv and 200 mg/m2 ivgtt), and actinomycin-D (0.5 mg), D7–8, at two-week intervals. Goserelin (3.6 mg) was injected before the beginning of chemotherapy and at four-week intervals during the treatment to protect the ovarian function. During the chemotherapy, the patient was monitored weekly for serum levels of β-hCG, and a rapidly decrease was detected. We observed normalization of the CA125 serum level after one course of chemotherapy. The β-hCG level decreased to normal after two and a half courses of chemotherapy and remained normal thereafter. The contrast pelvic MRIs performed once a month during the chemotherapy showed reduced lesion which became undetectable during the fourth course. The patient remains without evidence of disease 32 months after chemotherapy, her menstruation recovered 12 months after chemotherapy, and gave birth to a healthy baby 25 months after chemotherapy.

Individual DNA polymorphic analysis was used to verify the presence or absence of paternal genetic material. DNA from paraffin-embedded tumor tissue was compared to the patients’ and her husband’s peripheral blood DNA. Manual microdissection of the tumor cells was performed to eliminate the contamination of maternal DNA. Following extraction of DNA from the formalin-fixed and paraffin wax embedded material (QIAamp DNA FFPE Tissue Kit, Qiagen, Valencia, CA, USA), and from blood samples (ZR Genomic DNA-Tissue MiniPrep Kit, Zymo Research, CA, USA) all samples were quantified by NanoDrop (Thermo Scientific, Wilmington, USA), and MicroreaderTM 21 ID system, MicroreaderTM 23sp ID system (Beijing Microread Genetics Co., Ltd., Beijing, China) were respectively used to amplify 10 ng DNA from each biopsy and blood samples. Amplified products were then detected using an ABI 3730xl Genetic Analyzer (Applied Biosystems, CA, USA). Electrophoresis results were analyzed using GeneMapper® ID v.3.2 (Applied Biosystems, CA, USA), and the genetic profiles of the biopsy and peripheral blood were compared.

We studied the genetic profiles of 43 highly polymorphic short tandem repeats (STRs) in DNA samples prepared from the patient, spouse and tumor. At 25/43 loci examined, the tumor specimen was shown to contain the paternal allele but not the maternal DNA (D21S11, D18S51, D6S1043, D3S1358, D7S820, D16S539, Penta D, D2S441, vWA, TPOX, TH01, FGA, D18S535, D19S253, D20S470, D22-GATA198B05, D16S539, D8S1132, D4S2366, D13S325, D9S925, D3S3045, D10S1435, D17S1290, D5S2500). At 18/43 loci examined, it could not be determined whether the tumor contained paternal allele because the patient and spouse shared one or two identical alleles (D19S433, D5S818, AMEL, D13S317, CSF1PO, D8S1179, Penta E, D12S391, D2S1338, D6S477, D15S659, D11S2368, D1S1656, D7S3048, D21S1270, D14S608, D12S391, D2S1338). Therefore, none of the loci could be proved to contain maternal allele only. At 20/43 loci examined, the tumor was triploid, which was in accord with the nuclear-heteromorphism of tumor cells. Twelve representative loci from these analyses were summarized in Table 1 and Fig. 2. In more than half (25/43) of the loci studied we were able to demonstrate the presence of paternal DNA in the tumor, indicating a gestational origin for the tumor.
Fig. 2

STRs analysis of the case. DNAs from the patient, spouse and tumor were amplified for 43 loci (21 not shown). P, patient; S, spouse; T, tumor

Discussion and conclusions

We summarized 48 cases of primary ovarian choriocarcinoma published since 1982 in Table 2 (ours included). Although most of the authors declared the reported cases were non-gestational choriocarcinoma, we reanalyzed the information and only 24 non-gestational choriocarcinoma and 2 gestational choriocarcinoma could be confirmed. The origin of other 22 cases was uncertain.
Table 1

Summary of polymorphic loci examined and the allelotypes of patient, spouse and tumor of 12 STRs (21 not shown)

Locus

Alleles

Patient

Spouse

Tumor

Paternal allele contained

 D3S1358

15

17

14

16

15

16

17

 D7S820

11

12

10

12

10

11

12

 D16S539

9

11

11

12

9

11

12

 Penta D

9

9

10

12

9

12

--

 D10S1435

12

13

11

14

12

13

14

 D17S1290

10

10

16

16

10

16

--

 D5S2500

11

15

11

12

11

12

15

Paternal allele not determined

 AMEL

X

X

X

Y

X

X

--

 D13S317

11

11

11

12

11

11

--

 CSF1PO

10

12

10

10

10

12

--

 D12S391

17

22

22

22

17

22

--

 D2S1338

24

25

23

24

24

25

--

Of 26 cases with confirmed origin, 19 were diagnosed with NGCO because they were young women with no intercourse [1, 418], one was diagnosed with NGCO because of XY gonadal dysgenesis (Swyer syndrome) [19], four were confirmed non-gestational [2023] and two gestational [24] by DNA analysis. Of patients assigned uncertain etiology, one was deduced GCO because of the presence of a corpus luteum [25], which can be suggestive, but not pathognomonic of gestational etiology; three patients were diagnosed with NGCO because of no intercourse in 10 years (G5P3) [26], long duration from the antecedent pregnancy(G1P1) [2], or husband’s undergoing vasectomy(G4P2) [27]. None of them can be excluded from gestational etiology since GCO has been reported to arise many years after an abortion or molar pregnancy, even in postmenopausal woman [2831]. Other cases were diagnosed with NGCO simply according to pathology.

How to define the origin of a primary choriocarcinoma of the ovary is difficult by clinical characteristics or traditional methods. The etiology of choriocarcinoma has been ascribed to four different sources: from maternal germ cell; from an ovarian pregnancy; from metastases from a regressed or occult uterine primary; or, in infants, from metastases of the placenta [32]. Choriocarcinoma of the ovary can arise from gestational tissue or pure germ cells of the ovary, and it would be useful to discriminate between tumors of different origins because of distinct therapeutic approaches, chemotherapy regimens, and prognosis [33]. Unfortunately, it is extremely difficult. Both gestational and non-gestational diseases exhibit identical clinical manifestations and histology. Histologically, combining with other germ cell elements such as embryonal carcinoma or dysgerminoma in the tumor imply a non-gestational etiology. When sole choriocarcinoma is present, it is difficult to distinguish the etiology by routine histologic examination, even no significant ultrastructural differences are displayed between non-gestational and gestational choriocarcinoma [5]. HCG level does not distinguish between two types of tumor. The absence of primary lesion in the uterus and the presence of a proliferative endometrium do not imply a primary choriocarcinoma either.

The clinical histology is helpful in assigning the etiology. A patient who is sexually immature, unable to conceive, or who has not engaged in sexually intercourse, must have NGCO. Postpubertal women who have been sexually active or have ever been pregnant, gestational origin is a strong possibility. However, they are assigned uncertain etiology unless the presence of paternal DNA in the tumor was determined. It is considered a non-gestational choriocarcinoma rather than a gestational one with an interval of 15 years or longer between the previous pregnancy and the presentation of choriocarcinoma [2], but this is still controversial.

Molecular diagnostic method has been described long time ago that paternal HLA antigens have been identified in GCO [34]. Short tandem repeats (STRs) are general existed DNA polymorphic loci in human genome, which are of highly specificity, genetic and somatic stability. It is very helpful in diagnosing ovarian choriocarcinoma by detecting paternal alleles of the tumor using STRs analysis. Lorigan was the first reported to diagnose choriocarcinoma by analyze DNA polymorphism [24]. More developed and automated techniques are utilized nowadays and become the golden standard of diagnosis of choriocarcinoma. With the increase of polymorphic loci involved in this analysis (43 loci in this report), a higher accuracy of diagnosis as GCO is concluded for the present case.

Treatment of primary ovary choriocarcinoma should be carefully chosen according to the situation of the patients. In a woman who desires further child-bearing, conservative surgery may be employed if the tumor does not involve the uterus or the other ovary. One patient was pregnant one year after the completion of chemotherapy, and gave birth to a healthy baby [34], and our patient also had the same good outcome. If the tumor is extensive, especially if the etiology is non-gestational, intensive cytoreductive surgery should be performed. Most of the patients under 30 years old (23/34) received conservative surgery, seven underwent radical surgery of total abdominal hysterectomy and salpingo-oophorectomy with or without pelvic lymph node dissection. In our case, the patient’s β-hCG level decreased rapidly after the cystectomy, and became negative during chemotherapy, no lesion was seen in MRI or ultrasound, so we didn’t perform any further surgery.

Advances in chemotherapy significantly promote the survival rate of ovarian choriocarcinoma, and make determinations of the etiology of an ovarian choriocarcinoma important. It is generally accepted that GCO can be treated with methotrexate, actinomycin D or etoposide as a single agent, or with combined agents such as EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) when high risk factors are present. However, NGCO are generally treated with BEP (bleomycin, etoposide, cisplatin) regimen. We assigned an EP-EMA regimen to our patient before the DNA analysis results came out hoping to cover both trophoblastic and germ cell tumor, and received satisfactory results.

It is generally believed that non-gestational choriocarcinoma has a worse outcome than a gestational one. We did not find any differences in prognosis between these two types of tumor probably because of the inadequacy of cases. Most of the patients (20/25) who underwent conservative surgery remained no evidence of disease for 1–16 years. Considering the early onset of non-gestational choriocarcinoma and the sensitivity to chemotherapy of gestational one, we recommend all patients who desire for future pregnancy can receive conservative surgery as long as the contralateral ovary and the uterus are intact.
Table 2

Choriocarcinoma of the ovary: a summary of cases

Authors

Age

Reproductive history

β-hCG (mIU/ml)

Surgery

Chemotherapy

Outcome

DNA polymorphic analysis

Gestational choriocacinoma

 Lorigan,1996 [24]

41

NS

151,500

TAH,BSO

BEP then EI

NED

Yes

 Our case

27

G0

>200,000

ROC

EP-EMA

NED 32 mo

Yes

Non-gestational choriocacinoma

 Vance,1985 [5]

9

NI

34

RO

VEP

NED 12 mo

No

 Raju,1985 [6]

16

NI

NS

Autopsy

None

DOD

No

 Axe,1985 [1]

6

NI

Normal

RO

None

NED 10 yrs

No

 Axe,1985 [1]

11

NI

Elevated

RO

MAV

DOD

No

 Sengupta, 1987 [7]

11

NI

NS

UO

NS

NS

No

 Spingler,1990 [19]

20

Swyer syndrome

NS

Yes,NS

NS

DOD

No

 Gribbon,1992 [8]

NS

NI

Elevated

Yes,NS

NS

DOD 4 mo

No

 Gribbon,1992 [8]

11

NI

Elevated

Yes,NS

NS

NED 1 yr

No

 Brown,1993 [9]

11

NI

NS

USO

NS

NED 32 mo

No

 Trigueros,1995 [10]

21

NI

200,000

TAH,BSO

PVB

NED 4 yrs

No

 Gungor,1999 [11]

16

NI

20,000

TAH, cytodeduction, omentectomy, appendectomy

EMA-CO

DOD 6 mo

No

 Inaba,2000 [12]

12

NI

1,100,000

RSO,LOC, conservative debulking surgery

BEP then EIC

NED 12 mo

No

 Goswami, 2001 [13]

18

NI

88,385

LSO,ROC,omental and peritoneal biopsies

MA and oral chlorambucil

NED 5 mo

No

 Ozdemir, 2002 [14]

13

NI

91,028

RSO

MAC

NED 9 mo

No

 Tsujioka, 2003 [20]

19

NS

110,000

LSO

EMA-CO

NS

Yes

 Koo,2006 [21]

33

G0

185,000

TAH,BSO,PLND

MAC

NED 18 mo

Yes

 Yamamoto,2007 [22]

19

NS

206,949

LO

EMA,then EA

NED 12 mo

Yes

 Kong,2009 [4]

10

NI

NS

LSO,partial omentectomy

PVB

NED 3 mo

No

 Exman,2013 [23]

24

G1P0

675,713

TAH,BSO

BEP

NED

Yes

 Heo,2014 [15]

12

NI

20,257

LSO

BEP

NED 14 mo

No

 Hayashi,2015 [16]

10

NI

6600

RSO

BEP

NED 62 mo

No

 Xin,2015 [17]

23

NI

18,000

tumor enucleation, LSO, pelvic peritonectomy, PaLND, omentectomy

BEP

NED 9 mo

No

 Wang,2016 [18]

13

NI

Elevated

TAH,LSO,debulking surgery

PVB

DOD 3 mo

No

 Wang,2016 [18]

13

NI

NS

LSO

NS

Lost follow-up in 1 yr

No

Uncertain etiology

 Jacobs,1982 [33]

30

G1P1

350,000

lumpectomy

MTX

NED 2 yrs

No

 Axe,1985 [1]

21

G1P1

Elevated

RO

MAV

NED 8 yrs

No

 Axe,1985 [1]

20

NS

Elevated

RO,appendectomy

MTX

NED 16 yrs

No

 Axe,1985 [1]

36

G4P2

Elevated

TAH,BSO,appendectomy

MTX

NED 19 yrs

No

 Axe,1985 [1]

35

G4P4

Elevated

TAH,BSO,PLND

PBC

NED 9 mo

No

 Kim,1990 [35]

16

G0

565,000

TAH,BSO

MAC

DOD during chemo

unknown

 Shin,1994 [36]

45

G6P3

132,005

TAH,BSO

MAC

NED 1 yr

unknown

 Byeun,1995 [37]

28

G3P2

13,378

RSO

EMA

NED 1 yr

unknown

 Balat,2004 [38]

28

NS

13,378

TAH,BSO,PLND

BEP

DOD during chemo

No

 Bazot,2004 [39]

38

P0

2,460,000

TAH,BSO

NS

NED 7 yrs

No

 Gerson,2005 [25]

33

G5P3

564,000

RSO,TAH,LSO,splenectomy

EMA-CO

NED 12 mo

No

 Corakci,2005 [34]

22

G1P1

15,050

TAH,BSO,PLND,PaLND

BEP

NED 25 mo

No

 Hirabayashi,2006 [40]

50

G0

704

TAH,RSO,PLND

P(ip) + TC,EP-EMA,P-EMA(ip)

DOD 10 mo

No

 Roghaei,2007[41]

47

G5P5, menopause

970

TAH,BSO,PLND

EMA-CO

NED

No

 Park,2009 [26]

55

G5P3

64,838

TAH,BSO

BEP

NED 20 mo

No

 Mood,2009 [42]

31

G9P1

>1000

RSO

EMA-CE

NED 7 yrs

No

 Mood,2009 [42]

32

G3P2

5500

TAH, BSO, debulking surgery and omentectomy

BEP to EMA-CE

NED 5 yrs

No

 Gon,2010 [43]

21

G0

279,000

RSO

NS

NS

No

 Lv,2011 [2]

48

G1P1

7664

sub-extensive TAH,BSO,PLND,PaLND

BEP

NED 12 mo

No

 Choi,2013 [27]

33

G4P2

74,612

LO,ROC

EMA

NED 5 yrs

No

 Haruma,2015 [44]

19

G0

373,170

LSO

EMA-CO

NED 10 mo

No

 Rao,2015 [45]

26

G1P1

8160

RSO,partial omentectomy, partial splenectomy and right adrenalectomy

BEO

brain metastasis 2 years after primary treatment

No

NS not stated, NI no intercourse, NED no evidence of disease, DOD dead of disease, mo, months, yr. year

In conclusion, Ovarian choriocarcinoma is very rare and aggressive. However, it has the potential to be cured by surgery followed by chemotherapy. Differentiation between two etiologies of the tumor can be achieved with DNA polymorphic analysis to detect the presence of paternal DNA, and it is necessary to distinguish between them to approach to an appropriate treatment, and better prognosis of a patient. Conservative surgery should be first considered in nonparous women, and distinguished regimens of chemotherapy are recommended in different etiology of the tumor. The protection of the ovarian function from the chemotherapy should be highly valued for young patients especially for who desire future pregnancy.

Abbreviations

GCO: 

Gestational choriocarcinomas

NGCO: 

Non-gestational choriocarcinoma

STRs: 

Short tandem repeats

β-hCG: 

β-human chorionic gonadotropin

Surgery

L/ROC: 

Left/right ovarian cystectomy

L/RO: 

Left/right oophorectomy

UO: 

Unilateral oophorectomy

L/RSO: 

Left/right salpingo-oophorectomy

USO: 

Unilateral salpingo-oophorectomy

BSO: 

Bilateral salpingo-oophorectomy

TAH: 

Total abdominal hysterectomy

PLND: 

Pelvic lymph node dissection

PaLND: 

Paraaortic lymph node dissection

Chemotherapy

A: 

Actinomycin-D

B: 

Bleomycin

C: 

Cyclophosphamide

E: 

Etoposide

I: 

Ifosfamide

M: 

Methotrexate

O: 

Vincristine

P: 

Cisplatin

T: 

Paclitaxel

V: 

Vincristine

Declarations

Acknowledgements

We thank Xianrong Zhou (Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China) for carrying out the pathological diagnosis and his assistance in the development of treatment plan of this case.

Funding

This study was supported by National Natural Science Foundation of China (No. 81572836).

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

NJ collected the clinical data, carried out the manual microdissection and drafted the manuscript. YC and EO carried out the experimental procedures and DNA polymorphic analysis. XT carried out the pathological diagnosis and immunohistochemical staining. XL participated in the treatment and reviewed the manuscript. WF conceived of the study and reviewed the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors have no competing interest, including relevant, financial interests, activities, and affiliations.

Consent for publication

Written informed consent was obtained from the patient and her spouse for blood specimen collection, DNA analysis, publication of this report and accompanying images. A copy of this written consent is available for review by the Editor-in Chief of this journal.

Ethics approval and consent to participate

This work has been approved by the ethics committee of Obstetrics and Gynecology Hospital of Fudan University (committee’s reference number No.2014–37).

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Authors’ Affiliations

(1)
Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University
(2)
Shanghai Gemple Biotech Co., Ltd
(3)
Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University
(4)
Shanghai Key Laboratory of Female Reproductive Endocrine-Related Disease, Fudan University

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