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Imaging of Pure Primary Ovarian Choriocarcinoma

Hôpital Tenon Paris 75020, France
Hôpital Tenon Paris 75020, France
Hôtel Dieu de Paris Paris, France

Germ cell tumors of the ovary include all neoplasms derived from primordial germ cells of the embryonal gonad [1]. Five percent of germ cell tumors are malignant, representing 3–5% of all ovarian carcinomas. To our knowledge, we report the first case of pure primary ovarian choriocarcinoma in which preoperative diagnosis was based on imaging and biologic findings.

A 38-year-old nulliparous woman presented with a 13-week history of amenorrhea. A pelvic mass was found at physical examination. The plasma human chorionic gonadotropin (HCG) level was markedly elevated (2,460,000 mIU/mL).

Pelvic sonography showed a left-sided well-defined mixed adnexal mass (Fig. 1A). Intrauterine and ectopic pregnancy were ruled out.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —38-year-old woman who presented with pure primary ovarian choriocarcinoma. Transabdominal sonogram shows 6-cm mixed echogenic left ovarian mass.

Unenhanced CT revealed a left laterouterine mass without fat. A large vascularized ovarian pedicle and irregular oversized arterial vessels were seen at the periphery of the mass during the arterial phase of dynamic CT (Fig. 1B). Significant contrast material uptake was observed in the peripheral solid portion of the mass. Abdominopelvic examination showed no extraovarian dissemination.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —38-year-old woman who presented with pure primary ovarian choriocarcinoma. Arterial phase of dynamic CT scan shows multiple irregular arterial vessels typical of malignant tumor.

Abnormal vessels and small cystic cavities in the irregular peripheral solid portion were displayed on T2-weighted MR images. High-signal-intensity foci in the solid portion and a large central area with high and intermediate signal intensities were suggestive of hemorrhage on T1-weighted images (Fig. 1C). Significant gadolinium uptake in the solid portion was suggestive of a highly vascularized tumor.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —38-year-old woman who presented with pure primary ovarian choriocarcinoma. Axial T1-weighted MR image displays hemorrhage in small cavities (small arrows) at periphery of left adnexal mass and right corpus luteum cyst (large arrow).

Bilateral adnexectomy and hysterectomy were performed. Pathologic examination confirmed the diagnosis of left ovarian mass with normal left tube, and normal uterus without trophoblastic tissue. Macroscopically, multiple cystic cavities with hemorrhagic content were seen in the peripheral solid portion, and a large central necrotic and hemorrhagic area was found (Fig. 1D). Microscopic examination showed thick, highly vascularized fibrovascular septa. The proliferation was composed of cytotrophoblast and syncytiotrophoblast cells. The patient received postoperative chemotherapy and remains symptom-free 7 years later.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —38-year-old woman who presented with pure primary ovarian choriocarcinoma. Photomicrograph of histopathologic specimen shows left ovarian mass containing multiple small cavities filled with blood in solid portion. Necrosis with hemorrhage is present in central part of mass.

Pure primary ovarian choriocarcinoma accounts for less than 1% of ovarian tumors [1]. Shiromizu et al. [2] recently studied 467 ovarian germ cell tumors and found only one choriocarcinoma. Choriocarcinoma is an aggressive tumor that may occur during or outside of pregnancy. Gestational choriocarcinoma of the ovary can be primary, associated with ovarian pregnancy, or metastatic, arising from a primary gestational choriocarcinoma in the uterus. Non-gestational choriocarcinoma of the ovary can be pure but is more frequently associated with other germ cell tumors [3].

Sonographic findings ruled out intrauterine and extrauterine pregnancy and revealed a left nonfunctional 10-cm adnexal mass. Images obtained during the arterial phase of dynamic CT were typical of a malignant tumor, although the presence of large vessels restricted to the periphery was unusual for a malignant epithelial tumor [4]. A peripheral irregular solid portion containing small cavities filled with hemorrhagic fluid and a large central portion with hemorrhagic and necrotic changes were suggestive of malignancy on MR imaging.

In summary, the highly vascularized nature of this mass, the presence of multiple cystic cavities in the solid portion, and central hemorrhagic and necrotic changes with high HCG level and an empty uterus are suggestive of ovarian choriocarcinoma.

References

1. Scully RE. Tumors of the ovary and maldeveloped gonads. In: Hartmann WH, ed. Atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology, 1979:243 –245
2. Shiromizu K, Kawana T, Sugase M, Izumi R, Mizuno M. Clinicostatistical study of ovarian tumors of germ cell origin. Asia Oceania J Obstet Gynaecol1991; 17:207 –215[Medline]
3. Talerman A. Germ cell tumors. Curr Top Pathol 1992;85:165 –202[Medline]
4. Buy JN, Ghossain MA, Sciot C, et al. Epithelial tumors of the ovary: CT findings and correlation with US. Radiology1991; 178:811 –818[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bazot, M. Articles by Buy, J.-N. Search for Related Content PubMed PubMed Citation Articles by Bazot, M. Articles by Buy, J.-N. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?