Choriocarcinoma is an intrauterine and gestational related invasive tumour. Primary choriocarcinoma in parenchymal organ specially in gastrointestinal tract are rare. A case of Primary Gastric Choriocarcinoma (PGC) associated with adenocarcinoma in a 27 years old woman is being reported.

1. Cow's milk protein allergy and intolerance—practical issues in diagnosis

2. Case Report
INTRODUCTION
Choriocarcinoma is a rapidly invasive, widely
metastatic human chorionic gonadotropin (HCG)-
producing neoplasm usually intrauterine and gestational
related. The rest of the choriocarcinoma arise in ectopic
pregnancies, the gonads, or midline locations
(mediastinum, retroperitoneum and pineal gland) as a
teratoma [1]. Primary choriocarcinoma in parenchymal
organ such as liver, lung, urinary bladders and
gastrointestinal tract are rarely reported [2].
Primary choriocarcinoma of the stomach is extremely
rare (0.08% of all gastric cancer and most such cases are
not diagnosed correctly before operation. Critical
evaluation and identification of the rare histological
patterns of gastric cancer play a significant role in the
diagnosis and determination of clinical out come of the
patient [3,4]. Most PGC have been reported to possess an
adenocarcinoma component of variable extent [1]. We
report a case of primary gastric choriocarcinoma
associated with adenocarcinoma in a 27 year old women.
CASE REPORT
A 27 year old lady was admitted in Apollo Hospitals
Dhaka through emergency department with the complaints
of frequent passage of black tarry stool several times for 10
days prior to admission. She also complaints of
generalized weakness for same duration. On examination,
she was conscious, oriented, afebrile, and severely
anaemic with soft, lax, non tender abdomen. Laboratory
examination revealed Hb level of 5.6 gm/dL, positive
occult blood test in stool, and normal liver function test.
Ultrasonogram of whole abdomen was normal. Upper GI
endoscopy showed an ulcerated gastric lesion treated with
adrenaline spray. She was treated conservatively
including 3 unit of PRBC transfusion. Repeat endoscopy
showed healing ulcer. She improved clinically and
discharged with advice. She came back again with the
same complains and found to be severely anaemic
(Haemoglobin level of 7 gm/dL) with mild leucocytosis.
Upper GI endoscopic biopsy of stomach revealed well
differentiated infiltrating adenocarcinoma. Following this
diagnosis a surgical consultation was taken. During
operation, an indurated focal lesion (2×2) cm seen along
the greater curvature at the anterior aspect of the stomach
wall (Fig.1). To determine the nature of the lesion and the
extent of surgery, frozen section was carried out.
Sections from the frozen specimen reveal a biphasic
histological picture with areas showing features of
adenocarcinoma while other areas show the features
resembling choriocarcinoma. To support the diagnosis,
patient’s serum sample was collected from the operation
room and Beta-hcg level was estimated which found to be
significantly raised (3260 mIu/mL). Subtotal gastrectomy
was done and the specimen was sent for routine
histological examination. Grossly, the resected specimen
consisted of a partial gastrectomy specimen measuring 16
cm in greater curvature and 11 cm in lesser curvature.
CO-EXISTENT PRIMARY CHORIOCARCINOMAANDADENOCARCINOMA
IN THE STOMACH
A Khaled*, M Ibrahim@
,A Rahman#
, LL Choudhury+
and TA Maser**
*Specialist, Department of Histopathology, @
Specialist, Department of Clinical Biochemistry, #
Senior Consultant,
Department of General Surgery, +
Senior Consultant, Department of Gastroenterology, **Senior Consultant,
Department of Histopathology, Apollo Hospitals Dhaka, Bangla Desh.
Correspondence to: Dr TA Maser, Senior Consultant, Department of Histopathology, Apollo Hospitals,
Dhaka, Bangla Desh.
Choriocarcinoma is an intrauterine and gestational related invasive tumour.Primary choriocarcinoma in
parenchymal organ specially in gastrointestinal tract are rare. A case of Primary Gastric Choriocarcinoma
(PGC) associated with adenocarcinoma in a 27 years old woman is being reported. Clinical presentation: A
27 year old lady complained of frequent passage of black tarry stool and generalized weakness for 10 days.
Upper GI endoscopy revealed an ulcerated lesion in the stomach which was later confirmed as
choriocarcinoma associated with adenocarcinoma by histopathological examination and serum beta-hcg (â-
hcg)level estimation.
Key words: Choriocarcinoma, Stomach, Adenocarcinoma.
Apollo Medicine, Vol. 7, No. 3, September 2010 214

3. Case Report
215 Apollo Medicine, Vol. 7, No. 3, September 2010
Three lymph nodes from greater curvature fat and one
lymph node from lesser curvature fat were isolated. Cut
surface of stomach shows, 5 cm from cardiac resection
margin, and an ulcerated growth with haemorrhagic and
necrotic surface measuring 3.5 cm in diameter. The
growth is situated on the grater curvature involving the
anterior wall of the stomach. The rest of the stomach
showed odematous and congested mucosa. On
microscopic examination, sections from the growth area
show a malignant tumour composed of dual components
closely adjoining each other at places. In some area, it
reveal the features of well differentiated infiltrating
adenocarcinoma (Fig. 2) where as in other areas, it reveal
the features of choriocarcinoma characterized by
proliferation of neoplastic cytotrophoblastic cells with
abundant eosinophilic cytoplasm, distinct cell border and
large vesicular nuclei having prominent macronucleoli
admixed with streaming masses of multinucleated
syncytotrophoblastic tumour cells and large areas of
necrosis (Fig.3) . Vascular embolization is also seen. Both
resected margins of the specimen were free off tumour. No
regional lymph node metastasis or omental seedling was
indentified. Based on the biochemical and histo-
morphological features, a diagnosis of primary gastric
choriocarcinoma co-existent with adenocarcinoma was
made. Post operatively, the patient was stable. Repeat
laboratory test for cancer markers show serum beta-hcg
level of 11,620 mIu/mL, serum AFP level of 0.6 IU/mL
and CA-125 level of 11.7 u/mL. CT scan reveals multiple
nodular lesion in the right lung with no detectable focal
lesion in the liver. At this stage, she was given multiple
blood transfusions and referred to an oncologist. But she
declined for further treatment and discharged on request.
DISCUSSION
PGC is a rare, rapidly growing and widely
metastasizing β-hcg producing tumour arises from the
trophoblastic germ cells [3,5,6]. Apart from gestational
choriocarcinoma, can occur as primary neoplasm in the
extragonadal sites such as mediastinum, liver, lung,
breast, prostate, urinary bladder and stomach which is an
extremely rare site [5,6]. They occur either in pure form,
accompany adenocarcinoma or occur is association with
Fig.1. An indurated focal lesion, 2x2 cm, seen along the
greater curvature at the anterior aspect of the stomach
wall.
Fig.2. Well differentiated adenocarcinomatous component of
the tumour.
Fig. 3. Choriocarcinomatous component with large areas of
necrosis.

4. Case Report
Apollo Medicine, Vol. 7, No. 3, September 2010 216
nontrophoblastic gonadal tissue [7]. However, in these
cases a metastasis from primary trophoblastic tumour
particularly in the gonads and uterus in females has to be
ruled out [3,8].
There are various theories regarding etiopathogenesis
of gastric primary choriocarcinoma. There is development
from a gastric teratoma or a displaced gonadal enlace or a
metastasis from in intrauterine lesion. However, based on
its occurrence with adenocarcinoma and common factors
regarding clinical features, age, sex and site distribution,
the widely accepted retro differentiation theory describes
the dedifferentiation of the adenocarcinoma cells to
embryonic ectoderm with subsequent trophoblastic
precursor cell metaplasia, choriocarcinoma overgrows
and eliminates the original adenocarcinoma [3,6,7].
Choriocarcinomas are often undiagnosed preope-
ratively because of their common association with
adenocarcinoma [9]. The endoscopic biopsy may be
inadequate to detect the precise histology like the present
case. Larger and multiple biopsies from the whole tumour
are recommended for proper diagnosis when extensive
haemorrhage and necrosis are present so that no minor
foci of other pathological components are missed (Hirano,
Mukta). Elevated serum levels β-hcg or presence of β-hcg
producing tumour cells per-se has no correlation with
tumour stage, grade or prognosis [3,10].
Choriocarcinomas have rapid hematogenous
dissemination unlike the lymphatic spread of
adenocarcinoma. The prognosis is poor with very high
mortality and a survival period of less than one year.
Chemotherapy regimes are not effective as compared with
the gestational chorocarcinoma. However, curative
resection, appropriate chemotherapy and absence of
synchronous liver metastasis are favorable prognostic
indicators [4].
Our case fits the clinical, biochemical and histological
criteria for a diagnosis of primary gastric
choriocarcinoma. The patient was young and presented
with gastrointestinal bleeding and a gastric mass clinically
suggestive of gastric adenocarcinoma. Suspicion during
frozen section, raised β-hcg level and routine
histopathological examination by multiple area sampling
proved the tumour to be a choriocarcinoma with a
component of adenocarcinoma consistent with the
dedifferentiation theory of histogenesis. Absence of a
germ cell tumour elsewhere excluded the possibility of a
metastasis. Metastatic disease to the lungs as documented
by the persistently raised β-hcg level and CT scan with
patient’s refusal to take chemotherapy suggested a poor
prognosis in the present case.
This is first reported case in this country. The report of
this case is important to add data to the scant literature
regarding this rare condition, to better understand its
histopathogenesis, to help others in its diagnosis and
management and eventually to improve patient treatment
and prognosis.
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