Persistent Arteriovenous Fistulae Following Chemotherapy of Malignant Trophoblastic Disease

Abstract

At the University College Hospital, Ibadan, Nigeria, it has been the practice for the last six years to employ pelvic angiography in the investigation of suspected malignant trophoblastic disease (1, 2). We have also performed selective pelvic angiography in selected cases during and after methotrexate and mercaptopu-rine chemotherapy (3, 4). We have observed in 7 patients arteriovenous shunting, evidenced on the initial pelvic angiograms, persisting after successful chemotherapy. This report briefly describes the clinical findings and the angiographic appearances in 3 of the 7 patients. Case Reports Case I: E. O., a 25-year-old Ibo woman, para 2 + 3, admitted with a diagnosis of choriocarcinoma made elsewhere. Four months earlier a benign hydatidiform mole had been evacuated by abdominal hysterotomy. Vaginal bleeding persisted, and two diagnostic curettages were undertaken in the next two months. Histological examination of the curettings showed choriocarcinoma. On admission to the University College Hospital, the human chorionic gonadotropin excretion was found to be 10,000 international units per liter of urine. A solitary pulmonary metastasis was evident on the chest radiograph. Pelvic angiography in late March showed enlarged uterine vessels and malignant trophoblastic vascular spaces with drainage by markedly dilated ovarian veins (Fig. 1, A and B). Chemotherapy consisting of methotrexate and 6-mercaptopurine was administered. The patient is still under observation, although there is no clinical or hormonal evidence of disease, the chorionic gonadotropin excretion having been normal for four months. The chest film is normal; follow-up pelvic angiography in June showed persistence of the enlargement of the right uterine artery and significant shunting of contrast medium to the right ovarian vein (Fig. 1, B and C). A systolic bruit is audible low in the right iliac fossa. Case II: S. O., a Yoruba woman, twenty seven years of age and para 2, admitted with a diagnosis of malignant mole established by histological examination of curettings at another hospital. Three months prior to admission she had aborted a hydatidiform mole. Vaginal bleeding persisted, and during the next ten weeks three diagnostic curettages were performed. At this stage, the patient was transferred to our care. The human chorionic gonadotropin excretion was 32,000 international units per liter of urine. A chest radiograph revealed multiple pulmonary metastases, and in April pelvic angiography showed that both uterine arteries were dilated; on the right side there was rapid filling of vascular spaces and early venous drainage by a dilated ovarian vein (Fig. 2, A and B). The response was satisfactory to combination chemotherapy of methotrexate and 6-mercaptopurine.