CEREBRAL METASTASI S PRO M CHORIOCARCINOM A
AND ONCOTI C ANEURYSM S
CASE REPOR T
PASQUALE GALLO* , OTHELL O M . FABIÃ O NETO , SÉRGI O F . RAUPP* , CARLOS A . ORDOVAS* , PAUL O P . OPPITZ *
SUMMARY — Cerebral metastasi s occu r i n 1 0 t o 20 % o f patient s wit h choriocarcinoma . W e describe th e twelft h patien t wit h oncoti c aneurysm s fro m choriocarcinom a verifie d b y cerebra l angiography. Th e importanc e t o conside r thi s diseas e i n a woma n o f childbearin g ag e wh o develop a n intracerebra l hemorrhag e o r a lesio n wit h mas s effec t i s emphasized , a s wel l a s laboratorial an d radiologica l characteristics . Therapeuti c approache s wit h chemotherapi c agents , surgery an d irradiatio n ar e discussed .
KEY WORDS : choriocarcinoma , cerebra l metastasis , oncoti c aneurysm .
Metástase cerebra l d e coriocarcinom a e aneurisma s oneótieog : relat o d e caso .
RESUMO — Metástase s cerebrai s ocorre m e m 1 0 a 20 % da s paciente s co m coriocarcinoma . Apresentamos o décim o segund o relat o n a literatur a mundial d e pacient e co m aneurisma s oncóticos, demonstrado s n a angiografi a cerebral , secundário s a metástase s cerebrai s d e co riocarcinoma. A importânci a d e s e considera r est a patologi a n o diagnóstic o dia s lesõe s expan -sivas e/o u hemorrágica s cerebrai s num a pacient e e m idad e reprodutiv a é salientada , be m com o as característica s laboratoriai s e radiológicas. O pape l d a quimioterapia , cirurgi a e radiote
-rapia n o manusei o dessa s metástase s é discutido .
PALAVRAS-CHAVE: coriocarcinoma , metástas e cerebral , aneurism a oncótico .
It i s impossibl e t o kno w th e exac t incidenc e o f choriocarcinom a i n Brazil . It i s know n tha t i n th e Unite d State s th e incidenc e i s abou t 1 i n 40,00 0 preg -nancies; o n th e othe r hand, in Southeas t Asi a it i s mor e frequent (1:3,708)4. Th e presence o f cerebra l metastasi s increase s th e mortality . Although , i t i s wel l known tha t th e prognosi s o f suc h diseas e improve d wit h th e us e o f ne w chemoterapic agent s 2,7,11,12,13,18,20.
We repor t th e cas e o f a patien t wh o develope d a choriocarcinom a metas -tasis o n whic h a n intracrania l hemorrhag e occurred . Th e presenc e o f oncoti c aneurysm coul d b e see n throug h th e cerebra l angiogram . I t i s th e twelft h cas e reported i n literature .
CASE REPOR T
ZFG, a 3 1 yea r ol d woman , ha d a mola r pregnanc y i n Octobe r 1987 . N o check-up s wer e made. Sh e ha d a norma l deliver y fou r month s befor e presentation , t o Crist o Redento r Hospita l in Januar y 1990 , wit h headache , nausea , vomitin g an d righ t hemiparesis . Compute d tomo -graphic (CT ) sca n (Fig . 1 ) reveale d a n intracrania l hematom a in th e let t temporoparieta l area. Twelv e hour s afte r admission , he r hemiparesi s worsened , an d sh e lapse d i n coma .
* Departament o f Neurosurger y an d Neuroradiology , Crist o Redento r Hospital , Port o Alegre. Aceite : 18-novembro-1992 .
and righ t media n lobe) . Seru m chorioni c gonadotropi n was elevate d (290,00 0 mlU/ml) . Th e cerebral angiogra m showe d tw o aneurysm s arisin g fro m branche s o f righ t middl e cerebra l artery an d on e arisin g fro m righ t posterio r cerebra l arter y (Fig . 4) . Varicositie s i n lef t parietal are a wer e show n (Fig . 5) . Chemotherap y wit h Osplati n an d Etoposid e wa s begu n and sh e improve d an d discharge d i n Apri l 199 0 with norma l C T sca n (Fig . 6) . Sh e die d i n June 199 0 b y gastrointestina l hemorrhag e a t home , an d he r famil y refuse d autopsy .
COMMENTS
Choriocarcinoma i s a trophoblas t malignant transformation , havin g invasiv e and metastati c characteristic s 12,14 . Soo n afte r it s appearanc e thi s neoplas m in -vades th e inferio r ven a cav a spreadin g emboli . Som e wil l reac h th e pulmona r circulation bein g asymptomati c o r followe d b y a n episod e simila r t o acut e pul -monar embolis m 14. Th e trophoblas t i n th e lun g ma y underg o furthe r malignan t trnasformation befor e metastasizin g elsewereS .
In authops y findings , th e patient s havin g cerebra l metastasi s o f chorio -carcinoma hav e shown , a t th e sam e time , pulmona r lesion s i n 9 5 t o 99°/o , bein g probable tha t th e cerebra l metastasi s i s a consequenc e o f them . Beside s lung s and brain , metastasi s i n th e pelvis , kidney , gastrointestina l tract , splee n an d heart occu r frequentl y 10,12,15,i9.
To evaluat e th e rea l incidenc e o f cerebra l metastasi s i s ver y difficul t be -cause o f th e disagreemen t fro m clinic an d postmorte m studies . Fro m 3 3 t o 60% they occu r i n mor e than o n site, havin g generall y irregula r sizes . It s developmen t is rapi d and being localize d mor e frequently i n th e cerebra l hemisphere s 10,12,19,22. The trophoblast s damag e bloo d vessel s developin g thrombosis , varicositie s an d aneurysms 2 1.
described, althoug h suc h aneurysm s shoul d occu r wit h greate r frequenc y becaus e they ma y b e obliterate d a t th e tim e o f aneurysma l ruptur e Th e previou s reports of thes e aneurysm s mostly occurred in the middle cerebral artery . Beside s being foun d in tha t artery , the y ma y occur i n othe r sites , concomitan t o r not , a s in th e posterio r cerebra l arter y an d i n th e callosomargina l arter y is. Seigl e e t al.1 9 believ e tha t th e presenc e o f suc h aneurysm s i n man y site s ca n b e relate d to metastasi s i n th e heart , althoug h i t wa s no t verifie d i n ou r patient .
Remission o f cerebra l metastasi s occurre d durin g chemoterapy , thoug h two month s afte r discharg e th e patien t die d becaus e o f gastrointestina l hemor -rhage. At present, th e choriocarcinom a treatmen t presente d som e progress , sinc e before chemotherap y thi s diseas e wa s fata l withi n tw o years . Man y combination s of chemotherap y agents ar e been recommende d although ther e wer e controversie s about th e appropriat e therapeuti c approac h whe n ther e ar e cerebra l metasta -sis 4,9,13. Som e insist upon chemotherapy associate d o r no t t o irradiatio n 3,4,9,13,18, while other s suppor t surgica l resectio n followe d b y irradiatio n an d chemothe rapy 8,20. We believe tha t th e craniotom y shoul d b e use d onl y i n extrem e situa tions suc h a s acut e an d progressiv e neurologica l deterioratio n o r whe n th e ce -rebral metastasi s persist s eve n thoug h usin g chemoterapy , indicatio n als o propos-ed b y other s 2,11,12.
The mos t commo n clini c presentatio n o f suc h metastasi s ar e headache , vomiting, seizur e an d hemiparesis ^w. A sudden presentatio n o f headache , vomit-ing an d los s o f consciousness , wit h o r withou t foca l sign s ar e characteristi c o f an intratumora l hemorrhage . I t i s easie r t o specif y th e diagnosi s whe n th e pre-sence o f choriocarcinom a i s alread y known . Thi s diseas e shoul d b e considere d in th e differentia l diagnosi s o f intracrania l hemorrhag e i n youn g woma n wit h recent pregnanc y withou t an y othe r ris k fator s 6,12,19.
The chorioni c gonadotropi n level s i n th e cerebrospina l fluid , seru m an d urine i s usefu l t o th e diagnosi s a s wel l a s durin g th e avaliatio n o f remissio n of choriocarcinoma1. Nongestaciona l choriocarcinom a a s wel l som e othe r form s of ger m cell s tumors , ma y caus e alpha-fetoprotei n t o ris e an d choriocarcinom a do not 6.
Roentgenograms o f th e ches t ca n demonstrat e on e o r mor e metastasi s an d it i s als o usefu l t o evaluat e th e remissio n o f th e disease . Th e CT scan ma y show a simila r imag e t o a n intracrania l hemorrhage . I t ca n als o b e presente d a s a high-density mas s surrounde d b y edema6*12.
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