A case of jejunal choriocarcinoma detected by capsule endoscopy and double-balloon endoscopy

A 34-year-old woman was admitted to our institution because she had melena and severe anemia (Hb 4.6 g/dL). She had a history of two abortions and two normal deliveries. Neither esophagogastroduodenoscopy nor total colonoscopy had identified the source of the bleeding. Capsule endoscopy revealed active hemorrhage in the jejunum and double-balloon endoscopy (DBE) showed a flat submucosal elevation at the mid-jejunum ([Fig. 1]).

Fig. 1 Double-balloon endoscopy showed a flat submucosal elevation at the mid-jejunum with an attached hemorrhagic ulcer from which a blood clot protruded.

A biopsy specimen was not obtained because of the tendency to bleed. Computed tomography (CT) of the chest showed a mass 25 mm in diameter in the right lower lobe. Diagnosis of the tumor was not confirmed, but the patient underwent surgery for progressive anemia. Two tumors were found in the resected specimen of the jejunum ([Fig. 2]).

Fig. 2 A segment of the jejunum 80 – 120 cm distal to the ligament of Treitz was resected. Tumors measuring 15 mm × 13 mm × 18 mm and 18 mm × 12 mm × 9 mm were found 5 cm and 27 cm from the proximal cut end of the jejunum.

The pathological diagnosis was choriocarcinoma of the jejunum ([Fig. 3], [4]).

Fig. 3 Pathological examination showed syncytiotrophoblasts and cytotrophoblasts proliferating mainly in the mucosal and submucosal layers, associated with massive bleeding. There was no evidence of adenocarcinoma in the area of either tumor (H&E, × 10).

Fig. 4 Immunohistochemical studies showed that the multinucleated giant cells expressed high levels of hCG. (hCG immunostain, × 370).

The serum human chorionic gonadotropin (hCG) concentration determined after pathological diagnosis was 14 587.6 m IU/mL. The primary lesion was not detected with additional enhanced MRI.

Choriocarcinoma usually arises in the genital organs; it can originate extragenitally [1], but rarely occurs in the small intestine [2]. Only 16 cases of small-intestinal choriocarcinomas have been reported [2] [3] [4] [5]. However, it is difficult to be certain from these reports whether the small-intestinal tumors were primary or metastatic. We could not detect genital tumors in the present case; however, the history of previous abortions and deliveries suggests a diagnosis of metastatic choriocarcinomas of the jejunum. Retrograde differentiation from adenocarcinoma may occur in the intestine [5], but the absence of adenocarcinoma cells in the resected small-bowel specimens in the present case also supports the diagnosis of metastatic choriocarcinoma. Although an endoscopic view of intestinal choriocarcinoma has been reported in only one patient with metastatic duodenal choriocarcinoma [3], recent clinical applications of DBE have enabled clinicians to detect deep small-intestinal lesions. This is the first report of jejunal choriocarcinoma detected by DBE.

Endoscopy_UCTN_Code_CCL_1AC_2AC

References

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