Case Report

A 26-year unmarried Indian female presented to the out patient department of surgery at our center. The lady presented with a gradually enlarging lump at the right shoulder region. On examination the lump was non tender, approximately 6 cm x 4 cm in the size, oval in shape; smooth surfaced, firm in consistency and with out any regional or generalized lymphadenopathy.

Fine needle aspiration cytology showed it to be an infected epidermoid cyst. It was excised completely under local anesthesia. The mass was found intramuscularly in deltoid muscle and was completely free from skin and subcutaneous tissue. A few fibers of the deltoid muscle had to be removed to excise the mass completely. The mass was 6 cm x 4 cm in size, oval in shape, brown red in color with smooth surface, hard in consistency and friable in nature.

Histopathology revealed it to be metastatic choriocarcinoma (Microphotograph HPF x 100). Patient did not have any complaint regarding genitourinary tract when she consulted for the swelling. Patient was thoroughly investigated for a primary site of Metastatic Choriocarcinoma when diagnosis was confirmed by excision biopsy.

Figure 1

Clinically the patient was anemic. No other complaints or findings were present. The patient gave a history of pregnancy for 2 month and abortion 3 years previously. There was no other history of pregnancy or abortion. On investigation the Hemoglobin was 9.5 gm%, Blood group O+, Total leukocyte count- 15800, and Differential leukocyte count- Polymorphs₈₀, Leucocytes₁₂, Monocytes₇, and Eiosinophil₁. In liver function test Total protein -6.7, Albumin-4.0, Globulin-2.7, Serum Bilirubin-3.7, alkaline phosphate-8.1, SGOT- 70, SGPT-85, and ßHCG were 110.2 MIU/ml on ELISA test. Chest X-ray showed a rounded opacity at the left lung base.

Ultrasonography revealed a large mass in the endometrial cavity with hemorrhage in that. Multiple metastases were present in the liver and peritoneal cavity. A large rounded opacity was present at the left lung base and probably was malignant in nature. The findings of abdominal CT were consistent with Ultrasonography findings. Kidney and bone marrow were free from metastases.

Histopathologically the findings were consistent with the diagnosis of Metastatic Choriocarcinoma. Microscopically tumor consisted of clusters and nests of cytotrophoblastic cells, separated by masses of syncitiotrophoblast, against hemorrhagic and necrotic background.

Patient was admitted for treatment but later she refused treatment and follows up and fled from the hospital. Her relatives reported later that she died after 3 months of diagnosis.

Discussion

Choriocarcinoma is not a common tumor. The majority of primary growth arises in the body of the uterus and develops first within the endometrial cavity₂.

The general metastasis develops early, the growth disseminates by way of the blood stream. Metastasis may occur on any organ of the body and deposits can be found in any organ of the body, the order of preference being lungs, Vagina, brain, liver, kidney and spleen₁. But the review of the literature shows no case has been reported so far in the skeletal muscles.

The rarity of this case led us to learn about the mode of presentation of a choriocarcinoma with absence of other signs and symptoms and not to ignore any lump or mass in the reproductive age group even if it may seems benign.

The other issue of presenting this rare case is to take caution during diagnosis and management of various subcutaneous swellings like cysts, fibroma, lipoma, sarcoma, or neurofibroma. There is always a possibility of the presence of metastatic cancer, which will require appropriate treatment.

Correspondence to

Gajendra Singh, M.S. 6 Buckboard Court, Bolingbrook, IL 60490 USA Phone: 630-269-2726 E Mail- tonygaj_99@yahoo.com