A case of lumbar metastasis of choriocarcinoma masquerading as an extraosseous extension of vertebral hemangioma

Abstract

We report here on an uncommon case of metastatic choriocarcinoma to the lung, brain and lumbar spine. A 33-year-old woman was admitted to the pulmonary department with headache, dyspnea and hemoptysis. There was a history of cesarean section due to intrauterine fetal death at 37-weeks gestation and this occurred 2 weeks before admission to the pulmonary department. The radiological studies revealed a nodular lung mass with hypervascularity in the left upper lobe and also a brain parenchymal lesion in the parietal lobe with marginal bleeding and surrounding edema. She underwent embolization for the lung lesion, which was suspected to be an arteriovenous malformation according to the pulmonary arteriogram. Approximately 10 days after discharge from the pulmonary department, she was readmitted due to back pain and progressive paraparesis. The neuroradiological studies revealed a hypervascular tumor occupying the entire L3 vertebral body and pedicle, and the tumor extended to the epidural area. She underwent embolization of the hypervascular lesion of the lumbar spine, and after which injection of polymethylmethacrylate in the L3 vertebral body, total laminectomy of L3, subtotal removal of the epidural mass and screw fixation of L2 and L4 were performed. The result of biopsy was a choriocarcinoma.

Keywords: Metastatic choriocarconoma; Spinal metastasis.

Fig. 1

Brain magnetic resonance image (T2WI) : A hemorrhagic lesion measuring 22 mm in size is seen with a focal, highly attenuated nodule with peripheral edema in the right parietal lobe.

Fig. 2

Pulmonary angiograph : The post-embolization angiogram demonstrating the embolization of the pulmonary hypervascular lesion with microcoils.

Fig. 3

Pre- and post-operative magnetic resonance images. The preoperative magnetic resonance images of the lumbar spine showing low signal intensity on T1WI (A) and focal enhancement on T1C+ (T1-weighted image enhanced) (B), and a lesion affecting the entire L3 vertebral body with the pedicle and extending to the epidural space in a curtain shape (C). The postoperative magnetic resonance images showing a significantly decreased epidural lesion compared with the preoperative images (D and E).

Fig. 4

Lumbar computed tomography (CT) scan of the L3 vertebra. The axial CT scan (A) and sagittal reconstruction CT scan (B) showing the vertical coarse bony trabeculae and soft tissue mass extending to the epidural space in a curtain shape, but the architecture of the cortical bone of the L3 vertebra is intact.

Fig. 5

Selective angiograms of the right L3 lumbar segmental artery. A : The pre-embolization angiogram showing a hypervascular lesion supplied from the right L3 segmental artery. B : The post-embolization angiogram demonstrating the embolization of the hypervascular lesion with polyvinyl acetate.

Fig. 6

Postoperative radiographs : X-ray on the first day after the operation (A) showing the injected PMMA cement on the L3 vertebral body, total laminectomy of L3, and L2-4 pedicle screw fixation. A follow-up X-ray ten months later (B) doesn't show any further bony destruction.

Fig. 7

Histological findings of the removed mass. A : There is a mixture of cytotrophoblastic and syncytiotrophoblastic cells (H & E, ×200). B : Human chorionic gonadotrophin positive cells are observed immunohistochemically (×200).