Abstract
Background
Cardiac metastases from choriocarcinoma are exceptionally rare, with only 11 cases reported in the literature to date.
Case Summary
Here we present the case of a 37-year-old woman with progressively worsening exercise intolerance, chest pain, and occasional hemoptysis after childbirth. Initial chest computed tomography revealed a pulmonary mass and a left atrial mass extending from the right inferior pulmonary vein. Blood test results raised suspicion of a gestational choriocarcinoma. The patient is responding to chemotherapy and is currently asymptomatic.
Discussion
Most previously reported cases were diagnosed postmortem, emphasizing the diagnostic challenges of this condition and the rarity of our case.
Take-Home Message
Choriocarcinoma should be considered as a potential differential diagnosis for intracavitary cardiac masses in young women, especially when involving the left atrium.
Key Words: cancer, chest pain, computed tomography, echocardiography
Visual Summary
History of Presentation
A 37-year-old woman (gravida 3, para 2, abortus 1) presented to the emergency department on 2 occasions with dyspnea, fatigue, and stabbing chest pain at rest. After her initial visit, her symptoms persisted, prompting her return 3 weeks later to the emergency department in December 2024 for further evaluation. Although no evidence of thromboembolism was found, chest computed tomography (CT) revealed a left atrial mass extending from the right inferior pulmonary vein. In addition, a lung opacity was identified in the right lower lung lobe (Figure 1, Video 1). Transthoracic echocardiography was performed, confirming similar findings within the heart (Figure 2, Video 2). On examination, she was normotensive and afebrile, but appeared pale, with crackles auscultated at the right pulmonary base. A 12-lead electrocardiogram showed sinus tachycardia, with no signs of ischemia (Figure 3).
Take-Home Messages
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Choriocarcinoma should be considered as a potential differential diagnosis for an intracavitary cardiac mass in young women, especially when involving the left atrium.
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A differential diagnosis can be made in case of persistent dyspnea using multimodal imaging.
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Multidisciplinary collaboration has a critical role in achieving an accurate diagnosis in this context.
Figure 1.
Chest Computed Tomography
Chest computed tomography reveals a left atrial mass (white arrow) extending from the right inferior pulmonary vein, accompanied by an opacity in the right lower lung lobe (blue arrow).
Figure 2.
Transthoracic Echocardiography
Transthoracic echocardiography shows a left atrial mass extending from the right inferior pulmonary vein (red arrow).
Figure 3.
12-Lead Electrocardiogram
Sinus tachycardia at 110 beats/min. No signs of ischemia.
Past Medical History
The background history included iron deficiency anemia and recently diagnosed hyperthyroidism. She also reported a 6-month history of irregular vaginal bleeding after a full-term delivery. During her initial visit in November 2024, a chest radiograph suggested multilobar pneumonia, for which she was treated with antibiotics. A follow-up chest radiograph was performed 2 weeks later, but her symptoms persisted (Figure 4).
Figure 4.
Chest Radiographs
Initial (A) and follow-up (B) chest radiographs reveal subtle hilar enlargement and a progressive increase in density in the right lower lobe.
Differential Diagnosis
Diagnoses that were initially considered included primary tumor (cardiac sarcoma, lymphoma), secondary tumor (metastasis), and thrombus.
Investigations
The patient was subsequently admitted to the cardiology department for further assessment, with oncology consultation requested for multidisciplinary input. Through this collaboration, β-human chorionic gonadotropin (HCG) levels were measured, revealing a markedly elevated concentration of 1 × 106 mIU/mL (normal for nonpregnant women <5 mIU/mL), strongly suggesting gestational choriocarcinoma. A vaginal ultrasound was also performed, showing no abnormalities. A subsequent chest-abdominal CT and a positron emission tomography CT scan were conducted. There were lesions with hypermetabolic activity in the lungs, heart, liver, and spleen (Figure 5), confirming the presence of metastases.
Figure 5.
Chest-Abdominal CT and PET-CT Scan
Chest-abdominal CT (A, B) and PET-CT scan (C, D) reveal lesions with hypermetabolic activity in the lungs, heart, liver, and spleen. CT = computed tomography; PET = positron emission tomography.
After choriocarcinoma diagnosis, a brain magnetic resonance imaging was performed, showing multiple bilateral cortical embolisms (Figure 6). Given the tumor's highly vascular nature and the consequent elevated risk of hemorrhage, and after excluding alternative differential diagnoses, a multidisciplinary team decided not to perform a biopsy. This decision was made in accordance with the European Society for Medical Oncology guidelines for gestational trophoblastic disease, which emphasize that biopsy of lesions is highly risky when bleeding cannot be adequately controlled and is not essential before initiating chemotherapy in cases of suspected choriocarcinoma.1 Although complete surgical excision may provide useful histologic confirmation when feasible, in this case, it was not considered possible due to the extensive metastatic involvement.
Figure 6.
Brain Magnetic Resonance Imaging
Brain magnetic resonance imaging scan showing an embolism in the head of the right caudate nucleus.
Management
The patient started treatment with a standard high-dose chemotherapy protocol for gestational choriocarcinoma (etoposide, methotrexate, and dactinomycin with cyclophosphamide and vincristine [EMA-CO] protocol).
Follow-Up
The patient is responding to chemotherapy and is currently asymptomatic. β-HCG levels significantly declined after initiating treatment (last measurement January 15, 0 mIU/mL) (Figure 7). A follow-up transthoracic echocardiography was performed in February, confirming the decrease in mass size (Video 3). Subsequently, a follow-up CT scan in March demonstrated a decrease in the size of the pulmonary, cardiac, and splenic lesions (Figure 8, Video 4).
Figure 7.
β-HCG Level Graph
Progressive decline of β-human chorionic gonadotropin (HCG) levels after initiating chemotherapy.
Figure 8.
Initial and Follow-Up CT Scans
Initial (A) and follow-up (B) thoracoabdominal computed tomography (CT) scans after initiation of treatment. Follow-up thoracoabdominal CT shows a reduction in the left atrial mass (white arrow) and a decrease in the opacity of the right lower lung lobe (blue arrow). A decrease in splenic masses is also observed after the initiation of chemotherapy.
Discussion
Choriocarcinoma is a highly vascular and invasive tumor.2 It can be classified as either nongestational or gestational. As seen in our case, <25% of gestational cases arise from a full-term pregnancy.3 Distinguishing between the two is crucial, as it influences treatment decisions and prognosis. Gestational choriocarcinoma is highly chemosensitive with a generally favorable prognosis, whereas nongestational choriocarcinoma tends to have a poorer outcome. Although patients with widespread metastatic disease typically have a poor prognosis, some patients with choriocarcinoma can still respond to chemotherapy, even at advanced stages.
Cardiac metastasis from choriocarcinoma is rare, with the majority of existing literature consisting of case reports. To date, only 11 cases of cardiac metastasis from choriocarcinoma have been reported globally.4 Notably, half of those were found in the left atrium. Among them, in only 1 case the right inferior pulmonary vein was also affected.5 Along with heart metastases, more than 50% of patients had metastases to other sites, primarily the lungs, kidneys, brain, and spleen.6 In most of the reported cases with cardiac involvement, the diagnosis was not confirmed until after the patient's death.
Gestational choriocarcinoma is a notorious clinical masquerader, presenting with a diverse spectrum of symptoms. Serum β-HCG levels serve as a crucial help for completing diagnosis, treatment monitoring, and follow-up of choriocarcinoma. Although abnormal vaginal bleeding is the most common symptom, many patients present with symptoms related to metastatic disease. Another presenting symptom can be hyperthyroidism, as seen in our patient.
In summary, our case highlights the importance of considering choriocarcinoma in the differential diagnosis when encountering an intracavitary cardiac mass in a young female patient, particularly in the left atrium.
Conclusions
Cardiac metastases from choriocarcinoma are extremely infrequent. When present, they often involve the left atrium. β-HCG levels play a crucial role in diagnosis. Early recognition and timely intervention are key to improving patient outcomes.
Visual Summary.
Left Atrial Metastasis in Gestational Choriocarcinoma or Multimodality Imaging
(A, B) Chest-abdominal CT reveals a large left atrial mass extending from the right inferior pulmonary vein, with additional lesions in the right lower lung lobe, liver and spleen. (C) Transthoracic echocardiography shows the left atrial mass. (D, E) PET-CT reveals intense hypermetabolic activity in all identified lesions (F) Brain MRI scan shows an embolic infarction.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Thoracoabdominal Computed Tomography
Thoracoabdominal computed tomography demonstrates a left atrial mass originating from the right inferior pulmonary vein, associated with an opacity in the right lower lung lobe. Additional lesions are noted in the liver and spleen.
Transthoracic Echocardiography
Transthoracic echocardiography shows a left atrial mass extending from the right inferior pulmonary vein.
Follow-Up Transthoracic Echocardiography
Transthoracic echocardiography shows a decrease in left atrial mass.
Follow-Up Thoracoabdominal Computed Tomography
Follow-up thoracoabdominal computed tomography demonstrates a decrease in the left atrial mass and a reduction in the right lower lung lobe opacity. A decrease in the size of the splenic lesions is also observed after the initiation of chemotherapy.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Thoracoabdominal Computed Tomography
Thoracoabdominal computed tomography demonstrates a left atrial mass originating from the right inferior pulmonary vein, associated with an opacity in the right lower lung lobe. Additional lesions are noted in the liver and spleen.
Transthoracic Echocardiography
Transthoracic echocardiography shows a left atrial mass extending from the right inferior pulmonary vein.
Follow-Up Transthoracic Echocardiography
Transthoracic echocardiography shows a decrease in left atrial mass.
Follow-Up Thoracoabdominal Computed Tomography
Follow-up thoracoabdominal computed tomography demonstrates a decrease in the left atrial mass and a reduction in the right lower lung lobe opacity. A decrease in the size of the splenic lesions is also observed after the initiation of chemotherapy.