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Pregnancy and delivery after successful treatment of epidural metastatic choriocarcinoma
GYNECOLOGIC
ONCOLOGY
6,464-466
(1978)
CASE REPORT Pregnancy and Delivery after Successful Treatment of Epidural Metastatic Choriocarcinoma A. KUTEN,
M.D.,
I. KOBRIN, The Northern Israel The Aba Khoushy
Y. COHEN, M.D., M. TATCHER, PH.D. M.D., AND E. ROBINSON, M.D.’ Oncology Center, RAMBAM Medical School of Medicine, Technion, Haifa,
Center, Israel
Received September 27, 1977 A case of cauda-equina compression due to epidural metastatic gestation choriocarcinoma is presented. Complete remission and disappearance of neurologic deficit were achieved by chemotherapy and radiotherapy, allowing subsequent normal pregnancy and delivery.
INTRODUCTION Gestational choriocarcinoma, localized or metastatic, is curable by chemotherapy in a high percentage of patients. The chemotherapeutic agents effective against this malignant disease are methotrexate, 6-mercaptopurine, vinblastine, and actinomycin D, administered singly or in combination [l]. Normal pregnancy and delivery after successful treatment of metastatic gestational trophoblastic disease can occur [2-41. However, pregnancy after chemotherapy and radiotherapy for lumbar epidural metastasis has not yet been reported. CASE REPORT
E. M., a 20-year-old female patient, was referred to the Department of Oncology at the RAMBAM Medical Center in July 1972. Eight months previously, during her third month of pregnancy, the patient underwent dilatation and curettage to remove a hydatidiform mole. Two months later, the patient suffered intermittent vaginal bleeding. Dilatation and curettage was performed again and material compatible with decidual tissue was obtained. Urine gonadotrophin studies were not performed. A month later the patient suffered low-back pain and progressive paraparesis and was admitted to the Department of Neurology in June 1972. Neurologic examination suggested cauda-equina ’ Associate Professor of Oncology, Head Department of Oncology, Established Investigator of the Chief Scientists’ Bureau, Israel Ministry of.Health. 464 0090-8258/78/0065-0464$01.00/O Copyright 0 1978 by Academic Press. Inc. All rights of reproduction in any form reserved.
GESTATIONAL
CARCINOMA:
CASE
REPORT
465
compression by a space-occupying lesion. This was confirmed by spinal tap and myelography. Chest X ray was normal. Urine gonadotrophin titer at that time was positive at 40,000 IU/24 hr. Material obtained by dilatation and curettage was again compatible with decidual tissue. The patient was transferred to the Department of Neurosurgery. She underwent laminectomy of L,-L, and an epidural tumor was partially resected. This was followed by slight improvement of the paraparesis. The histology showed choriocarcinoma. After the operation the patient received a 5-day course of methotrexate, 25 mg daily, and was then discharged. About 2 weeks later she returned with complete paralysis of the right lower limb and severe paresis of the left leg. She was hospitalized at the Department of Oncology and received cobalt radiotherapy to the lumbar region, D,,-S, (8x l&cm field, 4000 rads in 4 weeks), together with a second course of methotrexate. There was marked improvement. In August of 1972 the patient was sent for rehabilitation and physiotherapy. At that time the methotrexate course was repeated twice. The last course was complicated by ulceration of the buccal mucosa. The patient improved and was walking with aid and, in September 1972, was discharged from the hospital. The fifth and last course of methotrexate was administered to her as an outpatient. Periodic evaluation post-therapy revealed normal levels of urine gonadotrophin. Follow-up examinations showed no evidence of recurrence of the disease. Two and a half years after completion of radiotherapy and chemotherapy, the patient became pregnant and, in November 1975, delivered a living single healthy female. The postpartum course was uneventful. At the last clinical evaluation in August 1976, no evidence of disease was found. The only neurologic deficit still existing was a right foot drop. The child was in good health.
DISCUSSION
The common sites for metastatic spread of gestational choriocarcinoma are the lungs, the vagina, the brain, the liver, the kidneys, and the ovaries. Epidural metastatic spread is relatively uncommon [5, 61. A patient with this kind of metastasis is classified as “high risk” and is unlikely to respond to single-drug chemotherapy [7]. Decompression surgery, radiotherapy, and combination chemotherapy should be considered in cases of metastatic epidural choriocarcinema with resultant progressive signs of spinal injury. There is no evidence for increase in maternal complications or in fetal abnormalities during pregnancy and delivery following chemotherapy for metastatic gestational trophoblastic disease [3, 81. Although afflicted by paraplegia due to metastatic cuda-equina compression, this patient was apparently cured by radiotherapy and single-agent chemotherapy, methotrexate. There was almost complete disappearance of the neurologic deficits. Dosimetrical calculations revealed that the ovaries were exposed to a maximum of no more than 90 rads, scattered and leakage radiation [9]. Gonadal exposure to this radiation dose, combined with five courses of methotrexate did not affect the patient’s fertility and capability for uneventful delivery of a normal child.
466
KUTEN
ET AL.
REFERENCES 1. Lewis, J. L., Jr. Current status of treatment of gestational trophoblastic disease, Cancer 38, 620-626 (1976). 2. O’Neill, E., Pelegrina, I., Hammond, C. B., Vincens, R., and Almodovar, A. R. Normal pregnancy and delivery after cerebral metastases of choriocarcinoma, Cancer 38, 984-986 (1976). 3. Van Thiel, D. H., Ross, G. T., and Lipsett, M. B. Pregnancies after chemotherapy of trophoblastic neoplasms. Science 169, 1326-1327 (1970). 4. Stilp, T. J., Bucy, P., and Brewer, J. I. Cure of metastatic choriocarcinoma of the brain. J. Amer. Med. Ass. 221, 276-279 (1972). 5. Brace, K. C. The role of irradiation in the treatment of metastatic trophoblastic disease. Radiology 91, 540-544 (1968). 6. Park, W. W., and Lees, J. C. Choriocarcinoma: A general review with an analysis of 516 cases. Arch. Patho/. 49, 73-104, 205-241 (1950). 7. Hreshchyshyn, M. M. Trophoblastic neoplasia, in Cancer medicine (J. F. Holland and E. Frei III, Eds.), Lea & Febiger, Philadelphia, pp. 1757-1767 (1973). 8. Ross, G. T. Congenital anomalies among children born to mothers receiving chemotherapy for gestational trophoblastic neoplasms, Cancer 37, 1043-1047 (1976). 9. Cohen, Y., Tatcher, M., and Robinson E. Radiotherapy in pregnancy. Radio/. Clin. Biol. 42,34-39 (1973).
ONCOLOGY
6,464-466
(1978)
CASE REPORT Pregnancy and Delivery after Successful Treatment of Epidural Metastatic Choriocarcinoma A. KUTEN,
M.D.,
I. KOBRIN, The Northern Israel The Aba Khoushy
Y. COHEN, M.D., M. TATCHER, PH.D. M.D., AND E. ROBINSON, M.D.’ Oncology Center, RAMBAM Medical School of Medicine, Technion, Haifa,
Center, Israel
Received September 27, 1977 A case of cauda-equina compression due to epidural metastatic gestation choriocarcinoma is presented. Complete remission and disappearance of neurologic deficit were achieved by chemotherapy and radiotherapy, allowing subsequent normal pregnancy and delivery.
INTRODUCTION Gestational choriocarcinoma, localized or metastatic, is curable by chemotherapy in a high percentage of patients. The chemotherapeutic agents effective against this malignant disease are methotrexate, 6-mercaptopurine, vinblastine, and actinomycin D, administered singly or in combination [l]. Normal pregnancy and delivery after successful treatment of metastatic gestational trophoblastic disease can occur [2-41. However, pregnancy after chemotherapy and radiotherapy for lumbar epidural metastasis has not yet been reported. CASE REPORT
E. M., a 20-year-old female patient, was referred to the Department of Oncology at the RAMBAM Medical Center in July 1972. Eight months previously, during her third month of pregnancy, the patient underwent dilatation and curettage to remove a hydatidiform mole. Two months later, the patient suffered intermittent vaginal bleeding. Dilatation and curettage was performed again and material compatible with decidual tissue was obtained. Urine gonadotrophin studies were not performed. A month later the patient suffered low-back pain and progressive paraparesis and was admitted to the Department of Neurology in June 1972. Neurologic examination suggested cauda-equina ’ Associate Professor of Oncology, Head Department of Oncology, Established Investigator of the Chief Scientists’ Bureau, Israel Ministry of.Health. 464 0090-8258/78/0065-0464$01.00/O Copyright 0 1978 by Academic Press. Inc. All rights of reproduction in any form reserved.
GESTATIONAL
CARCINOMA:
CASE
REPORT
465
compression by a space-occupying lesion. This was confirmed by spinal tap and myelography. Chest X ray was normal. Urine gonadotrophin titer at that time was positive at 40,000 IU/24 hr. Material obtained by dilatation and curettage was again compatible with decidual tissue. The patient was transferred to the Department of Neurosurgery. She underwent laminectomy of L,-L, and an epidural tumor was partially resected. This was followed by slight improvement of the paraparesis. The histology showed choriocarcinoma. After the operation the patient received a 5-day course of methotrexate, 25 mg daily, and was then discharged. About 2 weeks later she returned with complete paralysis of the right lower limb and severe paresis of the left leg. She was hospitalized at the Department of Oncology and received cobalt radiotherapy to the lumbar region, D,,-S, (8x l&cm field, 4000 rads in 4 weeks), together with a second course of methotrexate. There was marked improvement. In August of 1972 the patient was sent for rehabilitation and physiotherapy. At that time the methotrexate course was repeated twice. The last course was complicated by ulceration of the buccal mucosa. The patient improved and was walking with aid and, in September 1972, was discharged from the hospital. The fifth and last course of methotrexate was administered to her as an outpatient. Periodic evaluation post-therapy revealed normal levels of urine gonadotrophin. Follow-up examinations showed no evidence of recurrence of the disease. Two and a half years after completion of radiotherapy and chemotherapy, the patient became pregnant and, in November 1975, delivered a living single healthy female. The postpartum course was uneventful. At the last clinical evaluation in August 1976, no evidence of disease was found. The only neurologic deficit still existing was a right foot drop. The child was in good health.
DISCUSSION
The common sites for metastatic spread of gestational choriocarcinoma are the lungs, the vagina, the brain, the liver, the kidneys, and the ovaries. Epidural metastatic spread is relatively uncommon [5, 61. A patient with this kind of metastasis is classified as “high risk” and is unlikely to respond to single-drug chemotherapy [7]. Decompression surgery, radiotherapy, and combination chemotherapy should be considered in cases of metastatic epidural choriocarcinema with resultant progressive signs of spinal injury. There is no evidence for increase in maternal complications or in fetal abnormalities during pregnancy and delivery following chemotherapy for metastatic gestational trophoblastic disease [3, 81. Although afflicted by paraplegia due to metastatic cuda-equina compression, this patient was apparently cured by radiotherapy and single-agent chemotherapy, methotrexate. There was almost complete disappearance of the neurologic deficits. Dosimetrical calculations revealed that the ovaries were exposed to a maximum of no more than 90 rads, scattered and leakage radiation [9]. Gonadal exposure to this radiation dose, combined with five courses of methotrexate did not affect the patient’s fertility and capability for uneventful delivery of a normal child.
466
KUTEN
ET AL.
REFERENCES 1. Lewis, J. L., Jr. Current status of treatment of gestational trophoblastic disease, Cancer 38, 620-626 (1976). 2. O’Neill, E., Pelegrina, I., Hammond, C. B., Vincens, R., and Almodovar, A. R. Normal pregnancy and delivery after cerebral metastases of choriocarcinoma, Cancer 38, 984-986 (1976). 3. Van Thiel, D. H., Ross, G. T., and Lipsett, M. B. Pregnancies after chemotherapy of trophoblastic neoplasms. Science 169, 1326-1327 (1970). 4. Stilp, T. J., Bucy, P., and Brewer, J. I. Cure of metastatic choriocarcinoma of the brain. J. Amer. Med. Ass. 221, 276-279 (1972). 5. Brace, K. C. The role of irradiation in the treatment of metastatic trophoblastic disease. Radiology 91, 540-544 (1968). 6. Park, W. W., and Lees, J. C. Choriocarcinoma: A general review with an analysis of 516 cases. Arch. Patho/. 49, 73-104, 205-241 (1950). 7. Hreshchyshyn, M. M. Trophoblastic neoplasia, in Cancer medicine (J. F. Holland and E. Frei III, Eds.), Lea & Febiger, Philadelphia, pp. 1757-1767 (1973). 8. Ross, G. T. Congenital anomalies among children born to mothers receiving chemotherapy for gestational trophoblastic neoplasms, Cancer 37, 1043-1047 (1976). 9. Cohen, Y., Tatcher, M., and Robinson E. Radiotherapy in pregnancy. Radio/. Clin. Biol. 42,34-39 (1973).