Metastatic Choriocarcinoma of the Small Intestine Presenting as Refractory Anemia and Melena.

Case Report

A 57-year-old man presented with fatigue and 2-week history of melena. Medical history included acromegaly and a desmoid tumor invading the superior mesenteric artery, causing a cardiac arrest 11 years earlier. Exam revealed no abdominal tenderness, melena in the rectum, and a hemoglobin of 4.8 gm/dL. An esophagogastroduodenoscopy and colonoscopy revealed no source of bleeding. Capsule endoscopy showed a mass in the small bowel (Figure 1). An anterograde double balloon enteroscopy demonstrated a 4–5-cm mass 300 cm past the pylorus (Figure 2). Biopsies were consistent with a fibrinopurulent exudate. He underwent surgical resection of the mass, and histologic examination revealed a focal high-grade carcinoma with choriocarcinoma features, with clear margins without lymph node involvement (Figure 3). Serum ß-hCG level was 9169 mIU/mL (normal <5 mIU/mL). An ultrasound of both testicles was normal. The patient died 7 weeks later due to multiple intracranial metastases.

Figure 1

Small bowel video capsule endoscopy showing mass at 1 hour and 43 minutes.

Figure 2

Anterograde double balloon enteroscopy demonstrating mass 300 cm past the pylorus.

Figure 3

Immunoperoxidase stain of the post-surgical specimen was positive for ß-hCG.

There have only been 14 reported cases of choriocarcinoma of the small intestine; 9 were believed to be metastatic lesions.1 Choriocarcinoma most commonly presents in females with hydatidiform moles, spontaneous abortions, and ectopic pregnancy.2 On rare occurrences, it presents in males, with the most common site of origin being the testes. Most experts state that before a choriocarcinoma in male patients can be considered to have originated in extragenital structures, multiple sections from serial blocks of the testes must be found free of cysts, scars, or tumors.3 Our patient's family declined an autopsy, so this may still be a likely site of the primary tumor. Extragonadal primary choriocarcinomas typically occur at midline structures such as the mediastinum, retroperitoneum, or pineal body.4 Microscopically, the specimen should have cytotrophoblast and syncytiotrophoblast, usually in alternating layers, without villi. ß-hCG immunoperoxidase stain may be used to support the diagnosis of choriocarcinoma. Once the diagnosis of a gastrointestinal tract choriocarcioma is established, the survival time is very short, ranging from days to 15 months.3

Disclosures

Author contributions: R. Heil wrote the manuscript, reviewed the literature, and is the article guarantor. T. Tran wrote and reviewed the manuscript. L. Stawick and B. Herschman reviewed the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.