JOURNAL OF MEDICALCASE REPORTS

McDonald-Burrows et al. Journal of Medical Case Reports 2014, 8:117http://www.jmedicalcasereports.com/content/8/1/117

CASE REPORT Open Access

Haemoptysis from a pulmonary arteriovenousmalformation in a post molar pregnancygestational trophoblast tumour patient managedby radiological embolisation: a case reportZoë McDonald-Burrows1, Rhian Davies2, Elizabeth Goode3, Candice Clarke4, James Jackson5, Michael Seckl6

and Philip Savage7*

Abstract

Introduction: Gestational trophoblastic tumours are a rare form of malignancy, which in the majority of cases arisefrom abnormal trophoblast cells formed in a complete molar pregnancy. These tumours are extremely sensitive tochemotherapy and high cure rates approaching 100% can be expected. The disease is usually limited to the uteruswhere the abnormal trophoblast proliferation and human chorionic production can lead to vascular changesincluding the formation of arteriovenous malformations.

Case presentation: We describe the case of a 28-year-old Caucasian woman who presented to the UnitedKingdom's Gestational Trophoblast Tumour Service with rising human chorionic gonadotropin levels following auterine evacuation for a complete molar pregnancy. She was commenced on chemotherapy but subsequentlyreported two episodes of haemoptysis. Computed tomography imaging demonstrated findings consistent with apulmonary arteriovenous malformation, probably due to a small pulmonary metastasis, complicated by recenthaemorrhage. These findings were confirmed on emergency pulmonary arteriography, and the pulmonaryarteriovenous malformation was successfully embolised.

Conclusions: Arteriovenous malformations secondary to gestational trophoblastic tumours at metastatic sites haveonly been reported in a very limited number of cases. When significant bleeding occurs, as in this case of apulmonary lesion, urgent referral for embolisation is indicated.

Keywords: AVM, Embolisation, Haemoptysis, hCG, Trophoblast

IntroductionGestational trophoblastic tumours (GTT) are character-istically highly vascular and can produce heavy or evenlife-threatening bleeding from the uterus or sites ofmetastatic disease [1]. Over 90% of cases of GTT resultfrom the continual growth of the abnormal trophoblastcells that are formed in a complete molar pregnancy.Molar pregnancies are rare and occur at a rate of ap-proximately one for every 600 conceptions and carryan approximate risk of malignant change of 14% forcomplete moles and 1% for partial moles [2].

* Correspondence: Philip.Savage@bccancer.bc.ca7BCCA Vancouver Island, Victoria, BC V8R 6V5, CanadaFull list of author information is available at the end of the article

© 2014 McDonald-Burrows et al.; licensee BioMthe Creative Commons Attribution License (htdistribution, and reproduction in any medium

The genetically abnormal malignant trophoblast cellsshare many of the characteristics of healthy trophoblastcells, including human chorionic gonadotropin (hCG)production, rapid division, the ability to invade surround-ing tissues and to stimulate angiogenesis and other vascu-lar changes. Fortunately gestational trophoblast tumoursare extremely sensitive to chemotherapy and modern curerates approaching 100% can be expected for patients whodevelop GTTafter a molar pregnancy [3].In the majority of GTT cases the disease is limited to the

uterus where the abnormal trophoblast proliferation andlocalised hCG production may lead to focal vascularchanges including the formation of arteriovenous malfor-mations (AVMs) [4,5]. The development of uterine AVMs

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is well characterised in patients with GTTs and while manyare asymptomatic, some can lead to life-threatening bleed-ing requiring treatment with hysterectomy or radiologicalembolisation [1].The most common site of metastasis in GTT are the

lungs, but the formation of AVMs at this or any otherextra-uterine site of spread has only been recordedrarely [6,7]. This case reviews the diagnosis of a pulmon-ary AVM (pAVM) in a patient with GTT and occult lungmetastases successfully treated with radiological embol-isation and chemotherapy.

Figure 2 Selective left pulmonary artery branch angiogramdemonstrates rapid arteriovenous shunting through thepulmonary arteriovenous malformation.

Case presentationA 28-year-old Caucasian woman underwent a uterineevacuation for a molar pregnancy at her local hospital andwas registered for follow up with the United Kingdom(UK) Gestational Trophoblast Tumour service. The histo-pathology review confirmed the diagnosis of a completemolar pregnancy and as such she was enrolled in the hCGsurveillance programme. After an initial early fall in herserum hCG level, her hCG level rose in two consecutivesamples, because of this she was reviewed in clinic 14weeks post-evacuation prior to consideration of chemo-therapy treatment.She had an unremarkable medical history, with two

normal pregnancies, no major surgery or illnesses andno regular medications. The routine investigations dem-onstrated an hCG value of 2070IU/L, a normal chest X-ray and no visible uterine mass on the pelvic Doppler

Figure 1 Axial computed tomography image at level of aorticroot demonstrates small left lower lobe pulmonaryarteriovenous malformation (arrow) with surrounding groundglass opacity consistent with recent haemorrhage.

ultrasound but some increased vascularity. These resultsconfirmed the indications for treatment and producedan International Federation of Gynecology and Obstet-rics (FIGO) prognostic score of 1. Following the UK’sstandard treatment protocols, chemotherapy treatmentwas commenced with the low-risk regimen of metho-trexate and folinic acid [3].The patient was well 6 weeks after the commencement

of chemotherapy but reported two modest episodes ofhaemoptysis and was readmitted for emergency

Figure 3 Postembolization pulmonary arteriogramdemonstrates complete occlusion of the pulmonaryarteriovenous malformation.

Figure 4 Axial computed tomography image at same level asFigure 1 performed 4 years after embolization shows metalliccoils and obliteration of pulmonary arteriovenousmalformation (arrow).

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investigation. Initial blood tests confirmed a normalclotting screen and platelet count, whereas a computedtomography (CT) scan of her thorax demonstrated a17mm lobulated nodule in the apical segment of her leftlower lobe. Surrounding this lesion, there was patchyground glass opacification consistent with pulmonaryhaemorrhage (Figure 1). The CT findings were typicalof a pAVM, probably due to a small pulmonary metasta-sis, complicated by recent haemorrhage.

Figure 5 Patient human chorionic gonadotropin levels during coursetreatment was changed to the etoposide, methotrexate and dactinomycinchorionic gonadotropin levels normalised 3 weeks subsequent to this chanetoposide, methotrexate and dactinomycin; HCG(S), human chorionic gona

An urgent referral was made to the interventionalradiology team and emergency pulmonary arteriographyconfirmed the presence of a pAVM (Figure 2) with twoseparate feeding vessels. The pAVM was successfullyembolised with magnetic resonance-compatible coils asshown in Figure 3 and led to resolution of the haemop-tysis. A follow-up thoracic CT 4 years after embolisationconfirmed that the pAVM had been cured as shown inFigure 4.Just prior to the embolisation procedure, her chemo-

therapy treatment had been changed to the etoposide,methotrexate and dactinomycin alternating with cyclo-phosphamide and vincristine regime as a result of a slowrate of hCG fall with methotrexate. Subsequent to thischange, her hCG levels normalised 3 weeks later andafter an additional 6 weeks of treatment chemotherapywas completed as shown in Figure 5. She remains well 4years later, is cured of her tumour, has gone on to haveanother healthy baby and has had no further episodes ofhaemoptysis.

DiscussionGestational trophoblast tumours are a rare but highly cur-able form of malignancy. The majority of cases occur as aresult of a complete molar pregnancy and are characterisedas hCG producing, highly vascular and chemosensitive tu-mours. The effect of the tumour-derived hCG on angio-genesis is well documented [4,5] and AVMs in the uterusare a relatively frequent event and generally simple to man-age with uterine artery embolisation for cases with heavyor persistent bleeding [1].

of treatment. Levels fell at a slow rate with methotrexate andalternating with cyclophosphamide and vincristine regime. The humange. Abbreviations: CO, cyclophosphamide and vincristine; EMA,dotropin.

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GTT metastases at other anatomical sites may also behighly vascular and have the potential to form AVMs thatcan lead to life-threatening haemorrhage [6,7]. In thiscurrent case a patient with low-risk post-molar pregnancyGTT developed haemoptysis during methotrexate chemo-therapy and imaging investigations demonstrated an AVMin her left lung. The most probable cause was that thiswas as a result of a small GTT metastasis that was toosmall to be visualised on the initial screening chest X-ray.The presentation, timing and clinical findings were con-sistent with this being a GTT-related AVM rather thanother aetiology. The vast majority of pAVMs occur inpatients with hereditary haemorrhagic telangiectasia inwhom they are usually multiple. In this patient there wasno family history or clinical evidence of this condition, inaddition, no other pAVMs were present in either lung.In uterine AVMs with light to moderate bleeding, the

usual management is to manage these expectantly asmany resolve spontaneously with successful chemother-apy treatment. However, in this case with a pulmonarylesion and the potential for life-threatening bleeding, weelected to control the bleeding risk promptly by per-forming the embolisation.In the UK the management of patients with post-

molar pregnancy GTT is centralised, which has allowedthe development of expertise in these rare cases. Fromthe almost 3000 other patients treated previously, nocases of bleeding from pAVMs have been recorded. As aresult the FIGO recommendation of a chest X-ray re-mains the appropriate investigation for assessment ofpotential lung metastases in these patients [8]. Clearly ifhaemoptysis occurs, as in this rare case, then more de-tailed assessment with CT is indicated.

ConclusionsAlthough we appreciate that pAVMs secondary to meta-static GTT are extremely rare, it is clear from this reportthat they are at risk of rupture causing haemoptysis. Whendiagnosed, we suggest that urgent referral for embolisationshould be considered to reduce the risk of bleeding.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanying im-ages. A copy of the written consent is available for re-view by the Editor-in-Chief of this journal.

AbbreviationsAVM: arteriovenous malformation; CT: computed tomography;FIGO: International Federation of Gynecology and Obstetrics; GTT: gestationaltrophoblastic tumour; hCG: human chorionic gonadotropin;pAVM: pulmonary arteriovenous malformation; MTXFA: Methotrexate andFolnic Acid; EMA: Etoposide, Methotrexate and Dactinomycin;CO: Cyclophosphamide and Vincristine.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsAll the authors have read and approved the final version of this manuscript. RD,EG, CC and PS were involved in writing the manuscript. RD and ZMB compiledthe final draft of the manuscript. PS revised the manuscript critically and was amajor contributor in writing the manuscript. JJ provided the radiological inputfor the case and prepared the images. EG, CC, JJ, MS and PS were involved inthe clinical care of the patient. PS is the corresponding author.

AcknowledgementsWe acknowledge all the medical, nursing and administrative team in theTrophoblast Service and Radiology Department.

FundingThere was no funding associated with this case report.

Author details1Ealing Hospital Trust, Southall UB1 3HW, UK. 2Velindre Cancer Centre, CardiffCF14 2TL, UK. 3Gastroenterology Dept, Norfolk and Norwich UniversityHospital, Norwich NR4 7UY, UK. 4Renal Unit, Hammersmith Hospital, LondonW12 0HS, UK. 5Department of Imaging, Hammersmith Hospital, London W120HS, UK. 6Charing Cross Hospital Department for Oncology, Hammersmith,London W6 8RF, UK. 7BCCA Vancouver Island, Victoria, BC V8R 6V5, Canada.

Received: 3 December 2013 Accepted: 17 February 2014Published: 3 April 2014

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doi:10.1186/1752-1947-8-117Cite this article as: McDonald-Burrows et al.: Haemoptysis from apulmonary arteriovenous malformation in a post molar pregnancygestational trophoblast tumour patient managed by radiologicalembolisation: a case report. Journal of Medical Case Reports 2014 8:117.