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Zhu et al. World Journal of Surgical Oncology 2014, 12:239 
http://www.wjso.eom/content/1 2/1 /239 



WORLD JOURNAL OF 
SURGICAL ONCOLOGY 



CASE REPORT Open Access 



Breast carcinoma with choriocarcinomatous 
features: a case report and review of the literature 

Yanyun Zhu 1+ , Mei Liu 2+ , Jinyu Li 1 , Fangfang Jing 1 , Ruixia Linghu 1 , Xiaoqin Guo 3 , Shunchang Jiao 1 * 
and Junlan Yang 1 



Abstract 

Background: Breast carcinoma with choriocarcinomatous features (BCCF) is a rare variant of breast cancer, 
characterized by high expression of human chorionic gonadotropin (HCG) in cancer cells such as multinucleated 
syncytiotrophoblast-like giant cells. The first case of BCCF was reported in 1981 by Saigo and Rosen. Only one case 
of BCCF was reported to show no component of breast ductal carcinoma, and only partially cancer cells, such as 
multinucleated syncytiotrophoblast-like giant cells, expressed HCG in all previous BCCF cases. Here, we report the first 
BCCF case without any component of breast ductal carcinoma in which HCG was found to express in all cancer cells. 

Case presentation: A 32-year-old female patient presented with a small lump in her left breast 3 years prior. The 
mass was clinically suspected to be breast infiltrating ductal carcinoma based on breast excisional biopsy and 
magnetic resonance imaging findings. Due to rupture and bleeding of the left kidney, the left kidney excisional 
biopsy was performed. After a retrospective analysis of the initial excised breast cancer and breast cancer metastatic to 
the kidney, the cancer cells were positive for HCG by immunohistochemistry, and multinucleated or mononucleated 
giant cells resembled syncytiotrophoblastic and cytotrophoblastic cells which could be seen in a background of poor 
differentiated breast carcinoma and extensive necrosis and hemorrhage in the lesion. Thus, a final diagnosis of BCCF 
and BCCF metastatic to the kidney was made. After combination of surgical resection (the affected left breast and left 
kidney wereremoved) and consecutive chemotherapy consisting of docetaxel, epirubicin, cisplatin, lobaplatin, and 
capecitabine, the patient achieved favorable therapeutic efficacy (the HCG level returned to normal values, the 
metastatic lesions in the lungs disappeared, and the survival was 37 months). Capecitabine was very efficient and highly 
recommended due to its superior efficacy in reducing the HCG level and eliminating the metastatic lesions in the lungs. 

Conclusions: This is the first report of a rare case of BCCF without any component of breast ductal carcinoma, featured 
by high expression of HCG in all cancer cells. Combination of surgery and chemotherapy (especially capecitabine) 
achieved a favorable therapeutic efficacy. 

Keywords: Breast cancer, Breast carcinoma with choriocarcinomatous features, Breast infiltrating ductal carcinoma, 
Chemotherapy, Human chorionic gonadotropin 



Background 

Breast carcinomas can produce various hormones normally 
not secreted by the breast, including human chorionic go- 
nadotropin (HCG), human placental lactogen (HPL), adre- 
nocorticotropic hormone (ACTH), and norepinephrine 
[1,2]. HCG has been detected in the serum in 12% to 33% 
of patients with breast carcinomas [3]. However, histologic 



* Correspondence: jiaosc2009@l 26.com; yangjl301@163.com 
+ Equal contributors 

'Department of Medical Oncology, Chinese PLA General Hospital, 28 Fuxing 

Road, Haidian District, Beijing 100853, China 

Full list of author information is available at the end of the article 

Bio Med Central 



examination of cancer did not reveal any evidence of 
choriocarcinomatous differentiation, nordid the clinical 
examination suggest any other source of HCG [2-4]. 
Breast carcinoma with choriocarcinomatous features 
(BCCF) is a rare variant of breast carcinoma and was 
first reported by Saigo and Rosen in 1981 [4], BCCF is 
characterized by HCG -expressing highly atypical cancer 
cells morphologically similar to choriocarcinoma cells 
admixed with a malignant epithelial and/or mesenchy- 
mal component [5]. Most cases of BCCF have shown 
breast-infiltrating ductal carcinoma or ductal carcin- 
oma in situ with choriocarcinomatous features [3,5]. 



© 2014 Zhu et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative 
Commons Attribution License (http://creativecommons.0rg/licenses/by/2.O), which permits unrestricted use, distribution, and 
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain 
Dedication waiver (http://creativecommons.Org/publicdomain/zero/1.0/) applies to the data made available in this article, 
unless otherwise stated. 



Zhu et al. World Journal of Surgical Oncology 2014, 12:239 
http://www.wjso.eom/content/1 2/1 /239 



Page 2 of 7 



Only one case of BCCF showed no component of breast 
ductal carcinoma [6]. In all previous BCCF cases, only some 
cancer cells, such as multinucleated syncytiotrophoblast- 
like giant cells, expressed HCG [3,5]. Here, we report a 
rare case of BCCF without any component of breast 
ductal carcinoma, featured by high expression of HCG 
in all cancer cells. 

In this case report, the history, physical examination, 
laboratory findings, imaging studies, and pathological 
findings of BCCF in a 32-year-old woman are described 
and previous literatures about BCCF are reviewed. 

Case presentation 

A 32-year-old woman, gravida 2 and paral, withregular 
menstruation, detected a small lump of 2 x 1.5 cm in her 
left breast upon self-examination in July 2010. The 
breast ultrasound confirmed the presence of a 1.8 x 1.2 
cm lump of low echo-levels in August 2010. In January 
2011, the position emission tomography-computer tom- 
ography (PET-CT) of the whole body revealed that there 
were metabolism-elevating occupying lesions in the left 
breast, left kidney, and two lungs. Computed tomog- 
raphy (CT) confirmed the occupying lesions in the lung 
and left kidney (Figure 1A,B). The core needle biopsy in 
the left breast was performed, but no cancer cells were 
detected. The levels of human chorionic gonadotropin 
(HCG) was 22,931 U/L (normal values: 0-5 U/L). In 
February 2011, the breast excisional biopsy was per- 
formed and a diagnosis of breast infiltrating ductal car- 
cinoma was made. In the chemotherapy regimen, one 
cycle was 21 days. Two cycles of docetaxel (75 mg/m , 
once per cycle) combined with epirubicin (75 mg/m 2 , 
once per cycle) reduced the lesions in the lungs and kid- 
ney and the HCG level (5,773 U/L at the end of the first 
cycle but 9,026 U/L at the end of the second cycle), 
while new lesions appeared in the lungs. The chemother- 
apy regimen was then changed to two cycles of docetaxel 
(75 mg/m 2 , once per cycle) and cisplatin (75 mg/m 2 , once 
per cycle), and the lesions in the lungs remained stable; 
the HCG level continued to decrease to 1,490 U/L at the 
end of the regimen. During this regimen, resection of the 
left kidney was performed due to rupture and bleeding. 
The left kidney excisional biopsy was also performed and 



a diagnosis of high-level infiltrating renal carcinoma 
(breast cancer metastatic to the kidney) was made. The 
chemotherapy regimen was changed to one cycle of 
docetaxel (75 mg/m , once per cycle) and lobaplatin 
(35 mg/m 2 , once per cycle), and the HCG level continued 
to decrease to 57.86 U/L at the end of the regimen. Due to 
the severe marrow depression of docetaxel and lobaplatin, 
the chemotherapy regimen was changed to three cycles 
of docetaxel (75 mg/m 2 , once per cycle) and capecita- 
bine (2 g/m 2 ) (one cycle means once-daily administra- 
tion for 2 weeks followed by 1 week of rest). At the end 
of the regimen, the HCG level continued to decrease to 
17.64 U/L and the lesions in the lungs remained stable. 
A single capecitabine was then used instead of doce- 
taxel and capecitabine. After two cycles of capecitabine 
(2 g/m 2 , one cycle means once-daily administration for 
2 weeks followed by 1 week of rest), the HCG level 
continued to decrease to 0.12 U/L as didthe lesions in 
the lungs. The excised breast cancer and breast cancer 
metastatic to the kidney were retrospectively analyzed 
using HCG immunohistochemistry (IHC) staining. The 
IHC results demonstrated that all the cancer cells strongly 
expressed HCG, and the final pathological diagnosis was 
corrected to BCCF and BCCF metastatic to the kidney 
(Figures 2 and 3). After a further 9 cycles of capecitabine 
(2 g/m 2 , one cycle means once-daily administration for 2 
weeks followed by 1 week of rest), the HCG level returned 
to normal values and the lesions in the lungs disappeared 
(Figure 1C). At this time, the patient was still alive (the 
survival was 37 months), and was undergoing her 26 th 
cycle of capecitabine (2 g/m , one cycle means once-daily 
administration for 2 weeks followed by 1 week of rest) 
with no additional treatment. 

Pathologic findings 

Grossly, the left breast of the patient was normal and 
BCCF did not protrude through the skin surface. The 
BCCF was 3.2 x 3.2 x 1.8 cm in size, and was a solid, 
well-circumscribed, and dark red mass, with extensive 
necrosis and hemorrhage in the lesion. The BCCF meta- 
static to the kidney was 5 x 3.5 x 2 cm in size, and was a 
solid, well-circumscribed, and chromatic mass, with ex- 
tensive necrosis and hemorrhage in the lesion. 




Figure 1 CT (computed tomography) imaging of the lung and kidney of the patient. Breast carcinoma with choriocarcinomatous features 
(BCCF) metastatic to the lung (A) and left kidney (B). The metastatic lesions are indicated with black arrows. (C) The lesions in the lungs 
disappeared after a further 9 cycles of capecitabine. 



Zhu et al. World Journal of Surgical Oncology 2014, 12:239 
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Figure 2 Histology of breast carcinoma with choriocarcinomatous features (BCCF). (A) Hematoxylin-eosin (HE) staining at a low magnification 
The BCCF showed well-demarcated borders with extensive hemorrhage (the BCCF is indicated with black lines), and no infiltrating ductal carcinoma 
and ductal carcinoma in situ found. Error bars represent 100 pm. (B) Hematoxylin-eosin (HE) staining at a high magnification. A sheet-like arrangement 
of oval-shaped epithelial cells with prominent nucleoli was seen. Multinucleated giant cells (indicated by black arrows) with oval nuclei, prominent 
multiple nucleoli, and irregular chromatin clumping resembling syncytiotrophoblastic cells could be also be seen. Error bars represent 50 pm. 
(C) Immunohistochemistry (IHC) of human chorionic gonadotropin (HCG) demonstrates that all the cancer cells show strong HCG staining. 
Error bars represent 50 pm. 



Histologically, the BCCF showed well-demarcated bor- 
ders with extensive hemorrhage, and no infiltrating 
ductal carcinoma and ductal carcinoma in situ could be 
found (Figure 2A). At high magnification, a sheet-like ar- 
rangement of oval-shaped epithelial cells with prominent 
nucleoli was seen. Multinucleated giant cells with oval 
nuclei, prominent multiple nucleoli, and irregular chro- 
matin clumping resembling syncytiotrophoblastic cells 
could also be seen (Figure 2B). The BCCF metastatic to 
the kidney showed a very similar pattern in histology 
(Figure 3A,B). The cancer (presented as a thin border of 
intact choriocarcinoma) was well-circumscribed and cys- 
tic, surrounded by normal renal tissue, with extensive 
hemorrhage around it (Figure 3A). In the background 
of hemorrhage, giant cells with prominent pleomorphic 
nuclei, and abundant acidophilic and vacuolated cyto- 
plasm resembling cytotrophoblastic cells could be seen 
(Figure 3B). In all, the BCCF and BCCF metastatic to 
the kidney were made up of proliferation of large sized 
cells with high nucleus/cytoplasm ratio and increased 
nuclear chromatin. Multinucleated or mononucleated 
giant cells resembling syncytiotrophoblastic and cyto- 
trophoblastic cells could be seen. This finding was 



similar to choriocarcinoma originating from genital 
tract. No subtypes of breast infiltrating ductal carcin- 
oma or ductal carcinoma were identified in the cancer. 
No lymphovascular invasion was identified. 

IHC staining was performed on paraffin-embedded tis- 
sue sections, using a standard avidin-biotin-peroxidase 
complex method. The IHC staining demonstrated that 
all the cancer cells strongly expressed HCG in the BCCF 
and BCCF metastatic to the kidney (Figures 2C and 3C). 
In BCCF, other IHC markers were described as follows: 
HER-1 (++); HER-2 (-); p53(-); Cyclin D 1 (-); ER (-); 
Ki-67 (+ >75%); PR (-); Top-II a (+50% to 75%); pl20 (++); 
CK5 (-); CK7 (+); CK20 (-); CK (+); EMA (+); and 
GCDFP-15 (+). In BCCF metastatic to the kidney, other 
IHC markers were described as follows: HER-2 (-); ER 
(-); Ki-67 (+ >75%); PR (-); CK (+); CK7 (+); CK20 (-); 
EMA (+); p63 (-); Vimentin (-), and PLAP (-). 

According to the IHC study findings, the diagnosis of 
BCCF and BCCF metastatic to the kidney was confirmed. 

Discussion 

BCCF is a rare variant of breast cancer, characterized by 
high expression of HCG in cancer cells such as 




■ 




Figure 3 Histology of breast carcinoma with choriocarcinomatous features (BCCF) metastatic to the kidney. (A) Hematoxylin-eosin (HE) 
staining at a low magnification. The BCCF metastatic to the kidney (presented as a thin border of intact choriocarcinoma, indicated with black 
lines) is well-circumscribed and cystic, surrounded by normal renal tissue, with extensive hemorrhage around it. Error bars represent 100 pm. 
(B) HE staining at a high magnification. In the background of hemorrhage, giant cells with prominent pleomorphic nuclei, and abundant acidophilic 
and vacuolated cytoplasm resembling cytotrophoblastic cells could be seen. Error bars represent 50 pm. (C) Immunohistochemistry of human 
chorionic gonadotropin (HCG) demonstrates that all the cancer cells show strong HCG staining. Error bars represent 50 pm. 



Zhu et al. World Journal of Surgical Oncology 2014, 12:239 
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multinucleated syncytiotrophoblast-like giant cells [5,7]. 
The origin of BCCF is not clear. Some researchers sug- 
gested that osseous and/or sarcomatoid metaplasia usu- 
ally occurs in the development of breast infiltrating 
ductal carcinoma [3]. If metaplasia occurs in the breast 
infiltrating ductal carcinoma expressing HCG, the breast 
infiltrating ductal carcinoma cells will show choriocarci- 
nomatous features [3]. Since the first BCCF was reported 
in 1981 by Saigo and Rosen [4], there have been 18 cases 
of BCCF reported (including thecase in our current 
study). Only one case of BCCF was reported to have no 
component of breast ductal carcinoma [6]. Furthermore, 
only partially cancerous cells, such as syncytiotropho- 
blastic cells or cytotrophoblastic cells-like giant cells, 
expressed HCG in all previous BCCF cases [3,5]. In our 
case of BCCF, no component of breast ductal carcinoma 
could be found, and HCG was found to be expressed in 
all cancer cells. 

We summarized the characteristics of all the 18 cases 
in Table 1 and Table 2. In the 18 cases, the age of all pa- 
tients ranged from 22 to 71 years (the average age is 
46.5 years) and most tumors were located in the right 
breast (13/18), although several tumors were also located 
in the left breast (5/18); our patient presented with left- 
breast tumors only. The tumors ranged from 1 to 10 cm, 
and the metastatic tumors had the same histology as the 
primary tumors. Most cases (16/18) of BCCF presented 
with breast ductal carcinoma, whereas only two cases 
presented with no breast ductal carcinoma, including one 
case reported by Hematiet al. [6] and the case in our 

Table 1 Summary of reports in literature 



study. The pathological feature of BCCF is similar to that 
of choriocarcinoma in the female genital tract [5,7]. The 
cytopathologic characteristics of BCCF were hemorrhagic 
necrosis in the background and multinucleated bizarre 
giant cells resembling syncytiotrophoblasts in the chorion. 
Another characteristic is a sheet-like arrangement of oval- 
shaped epithelial cells with prominent nucleoli considered 
to be intermediate trophoblasts. The positive HCG stain- 
ing contributes to the diagnosis of BCCF. The pathological 
feature of BCCF in our case is similar to that reported by 
Hematiet al. [6]; both cases presented with poor differenti- 
ated carcinoma, with no component of breast ductal car- 
cinoma or other types of breast cancer, extensive necrosis 
and hemorrhage in the lesion, and multinucleated or 
mononucleated giant cells resembling cytotrophoblastic 
cells or syncytiotrophoblastic cells could be seen. The per- 
centage of HCG-positive cancer cells varied in all the 18 
cases. Murata et al. reported that the percentage of HCG- 
positive cancer in all cancer cells was estimated to be 2% 
to 3% [7], whereas a percentage of -30% was also reported 
by Resetkova et al. [8]. In Hematiet al.'s case, only some- 
cancer cells were found to express HCG [6]. It is note- 
worthy that, in our case, approximately 100% of the 
cancer cells expressed HCG. However, the mechanism 
underlying the high expression of HCG in our case re- 
mains to be elucidated. 

The diagnosis of BCCF is difficult, and should be dis- 
criminated from many other diseases. Initially, the first 
differential diagnoses were metastatic choriocarcinoma 
to the breast and poor differentiated anaplastic breast- 



Patient 


Age (years) 


Localization 


Size (cm) 


LN 


IDC-DCIS 


HCG 


HPL 


CK 


HER-2 


Reference 


1 


32 


L 


3.2 






+ 


/ 


+ 




Present study 


2 


38 


R 


5 


44/44 


+ 


+ 


/ 


+ 


/ 


[7] 


3 


50 


R 


/ 


0/20 


+ 


+ 


/ 


+ 


/ 


[9] 


4 


32 


R 


/ 


/ 


/ 


+ 


/ 


/ 


/ 


[10] 


5 


56 


R 


3.5 




+ 


+ 


/ 


+ 


/ 


[11] 


6 


38 


R 


1.0 


/ 




+ 


/ 


+ 




[8] 


7 


54 


R 


10 




+ 


+ 


/ 


+ 




[8] 


8 


59 


R 


2.5 


4/19 




+ 


+ 


+ 


+ 


[3] 


9 


48 


R 


2.5 


0/16 


+ 


+ 


+ 


+ 


+ 


[3] 


10 


58 


R 


4 


12/19 


+ 


+ 


+ 


+ 




[3] 


1 1 


49 


R 


1.6 




+ 


+ 


+ 


+ 




[3] 


12 


55 


L 


2.5 




+ 


+ 


/ 


/ 


/ 


[4] 


13 


/I 


R 


2.5 


20/21 


Mucoid 


+ 


/ 


/ 


/ 


[12] 


14 


22 


L 


4 


/ 


+ 


+ 


/ 


/ 


/ 


[13] 


15 


53 


L 


3.5 


0/10 


+ 


+ 


/ 


/ 


+ 


[14] 


16 


50 


R 


4 


0/19 


+ 


+ 


/ 


/ 




[14] 


17 


31 


L 


/ 


/ 


+ 


+ 


/ 


+ 




[15] 


18 


41 


R 


3 


3 




+ 


/ 


/ 


/ 


[5] 



Zhu et al. World Journal of Surgical Oncology 2014, 12:239 
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Table 2 Summary of reports in literature (continued) 



Patients 


ER 


PR 


Ki-67 


EMA 


PLAP 


P53 


Follow-up 


Metastasis 


Treatment 


References 


I 






+ 


+ 






DFS 


Lung, kidney 


S + C 


Present study 


2 






/ 


+ 


+ 


/ 


Died 


Lung, chest wall, liver 


S+C+R+E 


[7] 


3 


+ 




/ 


/ 


/ 


/ 


/ 


No 


S 


[9] 


4 


/ 


/ 


/ 


/ 


/ 


/ 


Died 


Left parietal lobe 


C + R 


[10] 


5 




+ 


+ 


/ 




/ 


DFS 


No 


S 


[11] 


6 






/ 


100 


/ 


/ 


DFS 


No 


S + C 


[8] 


/ 






/ 


/ 


/ 


/ 


Died 


Back neck, Pelvis, lungs 


S + C 


[8] 


8 






+ 


17 


/ 




Lost 


/ 


S + C + R 


[3] 


9 






+ 


■-10 


/ 


+ 


DFS 


No 


S + C + R 


[3] 


10 


+ 






10 


/ 


+ 


DFS 


No 


S + C + R 


[3] 


1 i 








2 


/ 




Lost 


/ 


s 


[3] 


12 


/ 


/ 


/ 


/ 


/ 


/ 


Died 


Lung, Lymph nodes 


S 


[4] 


13 


/ 


/ 


/ 


/ 


/ 


/ 


DFS 


Lymph nodes 


S + E 


[12] 


14 


/ 


/ 


/ 


/ 


/ 


/ 


/ 


Lungs, skin 


C 


[13] 


15 






+80% 


/ 


/ 




DFS 


No 


S 


[14] 


16 






+80% 


/ 


/ 


+ 


DFS 


No 


S 


[14] 


17 






/ 


/ 


/ 


/ 


/ 


/ 


S + C 


[15] 


18 


/ 


/ 


/ 


/ 


/ 


/ 


Died 


Lung, Liver, Kidneys 


C 


[5] 



"+", Positive: Negative; "I", Unknown. "Lost", Lost to follow-up. 

L, Left breast; R, Right breast; LN, Lymph node status; IDC-DCIS, Infiltrating ductal carcinoma-ductal carcinoma in situ; HPL, Human placental lactogen; HCG, Human 
chorionic gonadotropin; CK, Cytokeratin; ER, Estrogen receptor; PR, Progesterone receptor; EMA, Epithelial membrane antigen; PALP, Placental alkaline 
phosphatase; DFS, Disease free survival; S, Surgery; C, Chemotherapy; R, Radiotherapy; E, Endocrine therapy. 



infiltrating ductal carcinoma. Most patients with meta- 
static choriocarcinoma to the breast are pregnant and 
have a definite history of reproductive system tumors, 
and primary breast cancer could not be present in the 
breast cancer. However, acomponent of primary breast 
cancer, such as breast-infiltrating ductal carcinoma and/ 
or ductal carcinoma in situ, could be commonly found 
in BCCF. Further, a positive staining of GCDFP-15 in 
BCCF also supports that BCCF is a primary breast can- 
cer [10,13]. Although our case presented with a compo- 
nent of poor differentiated carcinoma without any 
component of breast ductal carcinoma, other evidence 
supports the diagnosis of BCCF: an immunohistochemi- 
cal profile of GCDFP-15 (+), CK7 (+), CK20 (-), CK (+), 
CK5(-), EMA (+), 32-year-old female with regular men- 
struation and no history of reproductive system tumors, 
and no pregnancy during disease occurrence. Thus, our 
case should be diagnosis as BCCF. Furthermore, the dif- 
ferential diagnosis with poor differentiated anaplastic 
infiltrating ductal carcinomas mainly depends on the 
positive staining of HCG [5], Another differential diag- 
nosis is the primary renal tumor expressing HCG (usu- 
ally high stage renal transitional-cell carcinoma), a very 
rare form of renal tumor [16]. However, in our case, no 
component of transitional-cell carcinoma was discov- 
ered, HCG was found to be expressed in both breast and 
kidney cancer, both of which showed a very similar 



pattern in histology. Further, animmunohistochemical 
profile of CK7 (+), CK20 (-), CK (+), and PLAP (-) in 
kidney cancer was found, supporting a diagnosis of the 
BCCF metastatic to the kidney. 

BCCF is a highly malignant breast cancer with a poor 
prognosis. Most patients die from multiple metastases 
within a few months [7,8]. However, two of four patients 
reported by Erhan et al. were disease-free 2 and 4 years 
after diagnosis, respectively [3], and BCCF patients who 
were disease-free 1 year after surgery have also been re- 
ported [6,10]. The etiology behind the poor prognosis of 
BCCF still remains to be elucidated, although a possible 
mechanism is described as follows: pregnancy-associated 
proteins such as HCG act as immunosuppressive re- 
agents, and make cancer cells in BCCF invade the im- 
mune defense of the host immune system, causing 
BCCF to become a highly invasive cancer [17-19]. The 
patient in our case underwent resection of both BCCF 
and BCCF metastatic to the kidney, and the serum level 
of HCG is normal. Thus, HCG might not play an immu- 
nosuppressing role in the presentcase. 

Current therapeutic strategies for BCCF mainly consist 
of endocrine therapy, surgery, and chemotherapy. So far, 
most cases of BCCF presented with double negative 
staining of estrogen and progesterone (our case also pre- 
sented with double negative staining of estrogen and 
progesterone), whereas only one case was estrogen- 



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Page 6 of 7 



positive and one case was progesterone-positive [3,11]. 
Tamoxifen-based endocrine therapy was ineffective in 
treating BCCF patients, whereas other endocrine therap- 
ies, such as gonadotropin-releasing hormone analogues, 
are also ineffective [5,7,12]. In all, there has not been ef- 
fective endocrine therapy towards BCCF so far. Surgery 
is generally considered to be effective in treating BCCF. 
Although there are BCCF patients who presented with 
multiple metastases and a short survival period after sur- 
gery [7,10], the BCCF patients who had a disease-free 
survival period of more than 1 year all underwent surgi- 
cal resection [3,8,9,14]. The two patients reported by 
Erhan et al. who were disease-free 2 and 4 years after 
diagnosis also underwent surgical resection [3]. The 
chemotherapy in BCCF regimen still remains unclear 
[5,8,15]. Fluorouracil or etoposide, methotrexate, vincris- 
tine, and doxorubicin are reported to be effective in treat- 
ing BCCF [7,10], whereas methotrexate, actinomycin D, 
and cyclophosphamide are reported to be ineffective [13]. 
Several studies suggested that BCCF patients received post- 
operative chemotherapy but their efficacy was not reported 
[3,8] . For the BCCF patients who could not receive surgery, 
chemotherapy has proved both effective [10] and ineffective 
[13]. In our case, the combination of surgery and chemo- 
therapy was used in treating BCCF, achieving a favorable 
therapeutic efficacy (the HCG level returned to normal 
values, the metastatic lesions in the lungs disappeared, and 
the survival was 37 months). In our chemotherapy regimen, 
capecitabine may play an important role in achieving favor- 
able therapeutic efficacy. The reason why capecitabine 
exerts superior therapeutic efficacy towards BCCF is de- 
scribed as follows. In common chemotherapy regimens for 
the treatment of choriocarcinoma, 5-fluorouracil is recog- 
nized as an effective drug, and capecitabine is an oral pro- 
drug of 5-fluorouracil [20,21]. In the tumor, capecitabine is 
selectively activated and exertsa therapeutic effect towards 
tumors [21]. Thus, capecitabine may also exert a superior 
therapeutic efficacy towards BCCF, which is breast carcin- 
oma with choriocarcinomatous features. 

Thus, combination of surgery and chemotherapy (espe- 
cially capecitabine) was recommended in treating BCCF. 

Conclusions 

This is the first report of a rare case of BCCF without 
any component of breast ductal carcinoma, featured by 
a high expression of HCG in all cancer cells. A combin- 
ation of surgery and chemotherapy (especially capecita- 
bine) achieved favorable therapeutic efficacy (the HCG 
level returned to normal values, the metastatic lesions in 
the lungs disappeared, and the survival was 37 months). 

Consent 

Written informed consent was obtained from the patient 
for publication of this case report and any accompanying 



images. A copy of the written consent is available for re- 
view by the Editor-in-Chief of this journal. 

Abbreviations 

ACTH: Adrenocorticotropic hormone; BCCF: Breast carcinoma with 

choriocarcinomatous features; CK: Cytokeratin; CT: Computed tomography; 

EMA: Epithelial membrane antigen; ER: Estrogen receptor; GCDFP-15: Gross 

cystic disease fluid protein 15; HCG: Human chorionic gonadotropin; 

HE: Hematoxylin-eosin; HPL: Human placental lactogen; IDC-DCIS: Infiltrating 

ductal carcinoma-ductal carcinoma in situ; IHC: Immunohistochemistry; 

LN: Lymph node status; PALP: Placental alkaline phosphatase; PET- 

CT: Position emission tomography-computer tomography; PR: Progesterone 

receptor. 

Competing interests 

The authors declare that they have no competing interests. 
Authors' contributions 

All authors have contributed substantially to the study. YZ, ML, JL, FJ, RL, and 
XG contributed to the design of the study, analysis of data, and writing of 
manuscript. JY and SJ contributed to the conception and design of the 
study. All authors read and approved the final manuscript. 

Acknowledgements 

This study was supported by the China Cancer Foundation (Grant No. 
XH201 1-0001). 

Author details 

'Department of Medical Oncology, Chinese PLA General Hospital, 28 Fuxing 
Road, Haidian District, Beijing 100853, China, department of Pathology, 
Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 
100853, China. 3 The First Out-patient Department, Bureau of Management 
and Social Security, Headquarters of the General Logistics Department of 
PLA, 22 Fuxing Road, Haidian District, Beijing 100842, China. 

Received: 23 October 2013 Accepted: 30 April 2014 
Published: 30 July 2014 

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Cite this article as: Zhu et at: Breast carcinoma with choriocarcinomatous 
features: a case report and review of the literature. World Journal of Surgical 
Oncology 201 4 12:239. 



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