Choriocarcinoma Liver neoplasm, metastases Liver neoplasm, angiography

33세/여자

The patient presented with upper abdominal pain, and distension and weight loss (4kg for one month). Her past medical history was unremarkable. An intrauterine device was inserted after the last pregnancy 4 years ago.

Hepatic metastasis from choriocarcinoma

Abdominal CT showed multiple, irregularly shaped, heterogeneously enhanced mass lesions in the liver and spleen, suggesting hepatic metastasis from splenic angiosarcoma or a multifocal hepatocellular carcinoma (Fig. 1).

Diagnostic celiac angiogram demonstrated multiple hypervascular masses with abnormal tumor vessels, saccular aneurysmal dilatations of the peripheral end of hepatic arteries on arterial phase and persistent visualization of vascular lakes on venous phase in the liver and spleen. But active bleeding was not identified (Fig. 2A, B). SMA angiogram showed normal portal venous flow. Diagnostic laparoscopic biopsy of the hepatic masses was done, and the histopathologic examination revealed metastatic choriocarcinoma in the liver. The serum beta hCG concentration was greatly elevated to 2,000,000 mIU/mL. Five days after the admission, sudden alteration of laboratory data suggestive of active bleeding was noted, and the patient underwent exploratory laparotomy, which revealed massive hemoperitoneum and active bleeding from the liver and spleen. Despite the surgical procedure, bleeding control was unsuccessful. Emergency celiac angiogram demonstrated massive extravasation of contrast media from the segmental branches of the both hepatic arteries as well as the branch of the splenic artery. After the superselection of the segmental arteries of both hepatic lobes and the spleen, immediate embolization was successfully performed using 16 Tornado microcoils (two 4 mm× 2 mm-sized coils, four 3 mm×2 mm-sized coils, five 5 mm×2 mm-sized coils, and five 6 mm×2 mm-sized coils; Cook, Bloomington, IN, U.S.A.) and Gelfoam particles. Post-embolization celiac angiogram demonstrated no further extravasation of contrast Fig. 3. After embolization using 16 microcoils and Gelfoam parti cles, celiac angiogram demonstrates no further extravasation of contrast media. media and intact portal flow (Fig. 3). However, levels of AST and ALT had continuously and rapidly increased, suggesting progression to hepatic failure and acidosis. The follow-up CT scan performed 13 days after embolization also showed an extensive, low attenuated area in the enlarged liver and spleen, representing massive hepatic infarction and necrosis. Although the exact cause of this hepatic infarction was unknown, it was assumed that the embolization was the probable cause. The patient’s condition continued to deteriorate, and she died on the 22th post embolization day.

Choriocarcinoma metastasizes hematogenously, producing a dramatic rise in beta hCG. The majority of metastases go to the lung (75%), vagina (50%), ovaries, brain, ureter, and bowel. Hepatic involvement is not common (10%), and occurs late in the disease course. Regression of the primary tumor after it has metastasized is not uncommon, and one third of cases are manifested by the complications of metastatic disease. Because of highly vascular nature of metastatic lesion similar to the primary tumor, hemorrhage from the tumor either spontaneously or after biopsy can be of a great concern. In our case, multiple hypervascular hepatic masses was presented with hemoperitoneum and severe anemia in a woman of childbearing age without an antecedent history of pregnancy or uterine abnormalities. Our initial diagnosis was either hepatic metastasis from splenic angiosarcoma or a multifocal hepatocellular carcinoma. In our case, the characteristic angiographic findings for metastatic choriocarcinoma in the liver were hypervascular masses with aneurysmal dilatations of the peripheral end of hepatic arteries (grapelike appearance) on arterial phase and persistent vascular lakes on venous phase, as compared with other hypervascular hepatic masses. These angiographic findings are similar to those of hemangioma, but hemangioma has unique CT findings that peripheral enhancement with centripetal flow unlike metastatic choriocarcinoma. Also metastatic choriocarcinoma can be differenciated from hepatocellular carcinoma because vascular lakes in the hepatocellular carcinoma do not retain the contrast media as long as those of choriocarcinoma. In this case, because we did not rule out a possibility of metastatic choriocarcinoma, diagnostic laparoscopic biopsy was performed, resulting in massive hemoperitoneum. In conclusion, the possibility of choriocarcinoma should be emphasized in women of childbearing age who present with hepatic masses. Because of the risk of hemorrhage, liver biopsy should be deferred until the blood serum level of beta hCG is measured, especially if typical angiographic findings of choriocarcinoma are demonstrated.

1. Hillard AE, Allen RW, Beale G. Metastatic choriocarcinoma: correlation of MRI, CT, and angiography. South Med J 1993;86: 1299-1302 2. Green CL, Angtuaco TL, Shab HR, Parmley TH. Gestational trophoblastic disease: a spectrum of radiologic diagnosis. Radiographics 1996;16:1371-1384 3. Alveyn CG, Loehry CA. Hepatic metastases due to choriocarcinoma. Postgrad Med J 1988; 64: 941-942

The contrast-enhanced CT shows multifocal ill-defined, heterogeneously enhanced masses in both lobes of the liver and the spleen.

A. Celiac angiogram on arterial phase shows multiple hypervascular masses with abnormal tumor vessels and saccular aneurysmal dilatations of the peripheral end of hepatic arteries in the liver and spleen. B. Celiac angiogram on venous phase shows persistent visualization of aneurysmal vascular lakes in the liver and spleen, but active bleeding is not identified.

After embolization using 16 microcoils and Gelfoam particles, celiac angiogram demonstrates no further extravasation of contrast media.