Spontaneous Uterine Perforation in a Choriocarcinoma Presenting with Pyoperitoneum

CASE DESCRIPTION

A29-year-old multiparous woman was admitted with complaints of foul-smelling vaginal discharge and fever for 2 months. She gave a history of evacuation 4 months back at a local hospital. The evacuation was done for history of 2 months amenorrhea. She was P3L3A1 and the last childbirth was 5 years back. On examination, the patient was severely pale with poor general condition. Per abdomen, the uterine size was corresponding to 12-14 weeks gestation, and globular and bilateral adnexal palpation was unremarkable. Ultrasound was done which revealed an enlarged uterus with a heterogeneous lesion arising from the body and fundus of the uterus.

Magnetic resonance imaging (MRI) pelvis revealed a uterus measuring 11.5 x 8.9 x 15.3 cm with loss of endomyometrial differentiation and a large ill-defined heterogeneous lesion with serosal and parametrial extensions suggesting gestational trophoblastic neoplasia, most likely invasive mole/choriocarcinoma. Both ovaries showed 3.5 x 2.3 cm unilocular nonenhancing cystic lesions. Within 2 days, the patient developed features of acute abdomen. Examination revealed a tense, tender, and rigid abdomen for which patient underwent an emergency laparotomy. Peritoneal cavity was filled with purulent fluid, uterus was 14 x 10 x 8 cm size with a 2 x 2 cm perforation in the left posterior uterine wall, and pus was oozing from it (Fig. 1A). Bilateral tubes and ovaries were grossly normal. On cut section of the uterus, endometrial cavity was dilated and filled with friable grey white to grey brown mass. Pus was seen in the cavity and necrosis was extending till the serosa in the posterior wall (Fig. 1B). Hysterectomy with bilateral salpingectomy and thorough peritoneal lavage was performed. Intraoperatively, the patient received 2-unit packed red blood cell (PRBC) and 1 was transfused postoperatively. Serum beta-hCG value was 2397 mIU/mL.

Histopathological examination of the specimen revealed choriocarcinoma invading the myometrium and the serosa was also invaded posteriorly (Fig. 2). Bilateral tubal histology was unremarkable. Fluid/pus cytology report was suggestive of predominantly inflammatory infiltrates of neutrophils, few macrophages, and scattered reactive mesothelial cells. No atypical or malignant cells were seen. Postoperatively, MRI brain was normal. Contrast-enhanced computed tomography (CECT) chest had multiple small soft tissue density nodules scattered diffusely in bilateral lung parenchyma suggestive of metastatic deposits. The final diagnosis was choriocarcinoma stage-III. Initially, single agent chemotherapy (methotrexate) was administered to the patient for two cycles with alternate oral rescue doses of folinic acid. In view of unsatisfactory response, EMA/CO regimen (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine) was initiated. This was accompanied by strict daily clinical evaluation, regular hemogram, liver and renal function tests, and beta-hCG follow-ups after every cycle. The patient had received injection filgrastim intermittently for chemotherapy-induced neutropenia. Chemotherapy was continued for six cycles until beta-hCG came to normal. Patient was reassessed after 1 year. There were no fresh symptoms and serum beta-hCG was normal.