Placental site trophoblastic tumour: a rare but potentially curable cancer

Insights into dovetailing GTD and Cancers

Gestational trophoblastic diseases (GTD) encompass a group of placental tumors which mostly arise due to certain fertilization defects, resulting in the over-proliferation of trophoblasts. The major characteristic of this diseased state is that β-hCG rises up manifold than that is observed during pregnancy. The incidence of GTD when analyzed on a global scale, figures out that there is a greater risk in South-East Asia, the reason of which remains unclear. An insight into any possible correlation of GTD incidence with cancers, other than choriocarcinoma, is being attempted here. Also, we review the recent developments in research on the molecular etiopathology of GTD. This review would render a wider eye towards a new paradigm of thoughts to connect GTD and breast cancer, which has not been into the picture till date.

A case of placental site trophoblastic tumor complicating nephrotic syndrome in which hysteroscopic biopsy did not yield a definitive diagnosis

Placental site trophoblastic tumor (PSTT) is the rarest subtype of gestational trophoblastic neoplasm. We present a case of PSTT complicating nephrotic syndrome. A 32-year-old woman experienced irregular menstrual bleeding and lower extremity edema 18 months after delivery. She was diagnosed with nephrotic syndrome and exaggerated placental site based on the hysteroscopic biopsy results. During follow-up, transvaginal color Doppler ultrasound showed an enlarged uterus filled with a hypervascular mass. Positron emission tomography–computed tomography showed diffuse accumulation in the entire uterus. The patient was diagnosed with PSTT only after total hysterectomy. Postoperatively, serum β-human chorionic gonadotropin decreased to within the normal range and her nephrotic syndrome resolved. She has remained without evidence of recurrence for 15 months. It is difficult to diagnose PSTT definitively. Most patients with PSTT are of reproductive age, therefore, to maintain fecundity, therapy development is expected.

[Placental site trophoblastic tumor: When do we suspect it and which treatment shall we decide?]

Tumors of trophoblast implantation site TTSI are rare gestational tumors. This case highlights the diagnostic difficulties and treatment of tumors of trophoblastic implantation site early. Patient of 28 years with no medical history, G1P1 who gave birth 11 months ago presented bleeding with an HCG level of 73IU that led to the diagnosis of early miscarriage. Treatment of miscarriage by hysteroscopy and curettage is complicated leading to the realization of an abdominopelvic CT and pelvic ultrasound that show an atypical uterine vascularity and an intracavitary heterogeneous mass. The pelvic MRI performed evokes a TTSI stage I. A hysterectomy with bilateral salpingectomy and ovarian conservation is achieved. Despite the standard treatment with surgery the HCG levels do not normalize before seven months after surgery. This indicates an adjuvant chemotherapy, the patient refuses. The presented case illustrates the diagnostic difficulties of the disease. He noted the importance of the second reading network proposed by the specialized center in Lyon. It also raises the question of adjuvant chemotherapy in some cases of early stage TTSI. The challenge is to define cases requiring adjuvant therapy. Predictors of chemotherapy in early stages could be tumor size, degree of infiltration of the myometrium and mutation p53. Amenorrhea, bleeding associated with uterine atypical vascularization, and atypical development of HCG<1000IU and/or unusual complications of treatment of miscarriage should evoke a tumor site trophoblastic implantation. Hysterectomy is the first treatment in early stages. Tumor size, degree of infiltration of the myometrium and mutation p53 are predictors to assess in multicentre studies to define the indications of postoperative chemotherapy.

Placental site trophoblastic tumor: Immunohistochemistry algorithm key to diagnosis and review of literature

•

Histologic morphology is frequently equivocal for PSTTs.

•

Histology combined with immunohistochemical staining was necessary to make the diagnosis.

•

PSTT confined to the uterus was successfully treated with surgery alone.

Placental site trophoblastic tumor, report of a case with unusual presentation

Placental site trophoblastic tumor (PSTT) is the rarest type of gestational trophoblastic tumors. Common presentation is irregular vaginal bleeding. A 26-year-old G1P1 woman presented with 15 month amenorrhea, a large uterine mass and plateau low level of serum human chorionic gonadotropin (hCG) which raised the possibility of PSTT. Since whole myometrium had been substituted with the large tumoral mass, hysterectomy was considered despite the young age of the patient. The patient has been in remission 36 months postoperatively without receiving any adjuvant treatment. It seems that plateau low levels of hCG in the presence of amenorrhea should prompt the possibility of PSTT.

Major surgeries performed for gestational trophoblastic neoplasms in a teaching hospital in Tehran, Iran

Objective

This study aim was to evaluate indications and outcomes of surgical interventions performed in patients with gestational trophoblastic neoplasm.

Methods

During January 1995 to December 2005, 110 patients with a diagnosis of persistent gestational trophoblastic neoplasm were treated in our Gynecologic Oncologic Department. Risk score calculation was carried out based on the revised FIGO 2000 scoring system for gestational trophoblastic neoplasm. Data from the patients' records and pathologic reports were analyzed by the chi-square and Fisher's exact tests and logistic regression. The Kaplan-Meier method including the log rank test was used to compare survival and recurrence.

Results

Eight patients did not complete their treatment and were excluded from the study. We evaluated treatment responses and outcomes in 102 patients. Seventy-nine patients (77.5%) responded fully to chemotherapy while 23 patients (22.5%) required surgery. Among 23 patients who underwent surgery, 10 cases (43.5%) had bleeding, and 13 cases (56.5%) had drug resistance. Several factors were found to be significantly different between the groups who responded to chemotherapy and those who needed surgery, including age (p=0.001), antecedent non-molar pregnancy (0.028), tumor stage (p=0.009), and pre-treatment risk scores (p=0.008). But, the total courses of chemotherapy (p=0.521), need to salvage chemotherapy (p=0.074), survival rates (p=0.714), and disease free survival rates (p=0.206) were not significantly different.

Conclusion

The data suggest that age, antecedent non-molar pregnancy, tumor stage and the prognostic score are clinical predictors of need for surgery. But, it dose not seem that surgery have any effect on the total course of chemotherapy, need for salvage chemotherapy, and patient prognosis.

Immunohistochemical studies of trophoblastic tumors

Although intermediate trophoblastic tumors (ITTs) are rare forms of trophoblastic neoplasia, their recognition is important as they require distinct therapeutic approaches. We have noted mixed trophoblastic tumors, with a combination of placental site trophoblastic tumor and epithelioid trophoblastic tumor patterns within the same case, and more frequently a combination of ITT with choriocarcinoma, which can create difficulty in the classification of these tumors. The distinction of the ITTs from choriocarcinoma is important because ITTs do not respond as well to chemotherapy as choriocarcinoma. In addition, ITTs can be confused with a variety of malignant neoplasms, the most common of which is poorly differentiated carcinoma of the cervix. Immunohistochemistry is one means of identifying trophoblastic tumors and of distinguishing them from other entities. We investigated the immunophenotype of 15 ITTs, 11 choriocarcinomas, and 10 primary cervical carcinomas using a panel of human placental lactogen, p63, CK5/6, CK18, human chorionic gonadotropin (hCG), human leukocyte antigen (HLAG), Mel-CAM, (CD146) carcinoembryonic antigen, CD10, inhibin, p16, and pan-keratin. CD10 was positive in all the cases of ITT and choriocarcinoma. HLA-G expression was present in 93% of ITTs and all choriocarcinoma cases. hCG was positive in 87% of ITTs and 100% of choriocarcinomas. We concluded that a panel consisting of HLA-G, CD10, and hCG can be very helpful in the identification of the ITTs. Adding CK5/6 to these markers can help to differentiate ITT from primary cervical carcinoma. However, the distinction of ITTs from choriocarcinoma cannot be accomplished on immunohistochemical studies, as they have similar immunophenotypes.

Placental-site trophoblastic tumor with PET scan-detected surgically treated lung metastasis

Metastatic placental-site trophoblastic tumor (PSTT) continues to be a diagnostic and management dilemma due to its relative resistance to chemotherapy and the difficulties in diagnosing such a rare tumor. We describe a 35-year-old woman with PSTT presenting with irregular bleeding and a mass in the lung. Dilation and curettage provided the diagnosis of PSTT by frozen section of the specimen. Subsequently, a total abdominal hysterectomy was performed and the patient received three cycles of EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine) Positron emission tomography (PET) scan confirmed a persistent lung nodule that was treated with wedge resection. She is currently in clinical remission. Surgery may have a role in salvaging a patient with persistent PET-positive disease after chemotherapy.

Placental site trophoblastic tumor: A study of 55 cases and review of the literature emphasizing factors of prognostic significance

OBJECTIVE

The placental site trophoblastic tumor is a rare form of gestational trophoblastic disease. Fifteen percent of reported cases have been fatal, but predicting behavior in individual patients has been challenging.

METHODS

The clinical, gross and histopathological features of 55 cases and 180 cases in the literature were analyzed for their effect on survival and in relation to tumor stage.

RESULTS

The 55 patients in our series were 20 to 62 (average 32) years of age. The tumors occurred on an average of 34 months after the last known gestation. 84% were stage I, 2% stage II, 5% stage III, and 9% stage IV. Serum levels of human chorionic gonadotropin (hCG) were elevated (average 691 mIU/ml) in 77% of the cases. The tumors were on average 5 cm in greatest dimension and were composed microscopically of infiltrative sheets of intermediate (extravillous) trophoblastic cells. The mitotic rate ranged from 0 to 20 (average 5.0) per 10 high power fields. The follow-up interval averaged 4.6 years. Eight patients (15%) died from metastatic tumor, and nine additional patients had metastases or a recurrence but were alive at last contact. The most common metastatic sites were the lungs, liver, and vagina.

CONCLUSIONS

Significant factors associated with adverse survival in the present series were age over 35 years (P = 0.025), interval since the last pregnancy of over 2 years (P = 0.014), deep myometrial invasion (P = 0.006), stage III or IV (P < 0.0005), maximum hCG level > 1000 mIU/ml (P = 0.034), extensive coagulative necrosis (P = 0.024), high mitotic rate (P = 0.005), and the presence of cells with clear cytoplasm (P < 0.0005). Only stage and clear cytoplasm were independent predictors of overall survival, while stage and age were the only independent predictors of time to recurrence or disease-free survival. In the literature, factors associated with survival were stage (P < 0.005), interval from preceding pregnancy of over 2 years (P = 0.029), previous term pregnancy (P = 0.046), high mitotic rate (P < 0.0005), and high hCG level (P = 0.037).

Regulatory role of hepatocyte nuclear factor-4alpha on gastric choriocarcinoma function

Gastric choriocarcinoma is a highly aggressive carcinoma, most probably originating from somatic cells in the gastric mucosal layer. We herein investigated the regulatory role of hepatocyte nuclear factor (HNF)-4alpha, a transcriptional regulator expressed in non-neoplastic and neoplastic gastric tissues, on functions of gastric choriocarcinoma cells. HNF-4alpha cDNA was stably transfected to a gastric choriocarcinoma cell line, SCH. Alterations in SCH cell functions such as histology, ultrastructure, proliferation, production of trophoblast-specific proteins, and chemosensitivity to methotrexate (MTX) were examined. Neither in vitro and in vivo proliferations nor HLA-G expression differed significantly between the mock-transfected and HNF-4alpha-transfected SCH cells, while suppressed human chorionic gonadotropin (hCG) secretions, increased human placental lactogen (hPL) and carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) immunoreactivity, and decreased chemosensitivity to MTX were seen in HNF-4alpha-transfected SCH cells. General histologic features in xenograft nodules were unaltered, but, ultrastructurally, fascicles of paranuclear filaments were significantly more numerous in HNF-4alpha-transfected SCH cells. These results indicated an HNF-4alpha-rendered functional regulation in SCH cells, suggesting a role of transcriptional factors abundant in gastric but not in trophoblastic tissues/cells on the functional modulation of gastric choriocarcinoma cells.

Gestational trophoblastic disease: is intensive follow up essential in all women?

OBJECTIVE

To determine the timescale of the registration process for gestational trophoblastic disease and its impact on hCG level at registration and subsequent need for chemotherapy.

DESIGN

A prospective observational study using a standardised protocol for registration, assessment and treatment for molar pregnancy.

SETTING

A supra-regional tertiary referral centre for gestational trophoblastic disease.

PARTICIPANTS

A total of 2046 consecutive women registered between January 1994 and December 1998 with a diagnosis of molar pregnancy.

METHODS

Data at and after registration, collected prospectively on a computerised database, were statistically analysed (by multiple logistic regression and ANOVA).

MAIN OUTCOME MEASURES

Relationship between length of time to and hCG value at registration; also the subsequent need for chemotherapy.

RESULTS

A total of 2046 women with a diagnosis of molar pregnancy were registered in the study period. The mean time interval between first evacuation and registration at the referral centre was 47 days (median 37, range 0-594). One hundred and five out of 2046 (5.1%) women needed chemotherapy. Sixty-three precent of the women (1296 out of 2046) had a normal level of urinary hCG (less than 40 IU/24 hours) at the time of registration and only one (0.08%) needed chemotherapy. Binary logistic regression analysis showed a statistically significant relationship between time to registration, hCG value, histology, pretreatment risk score and decision to administer chemotherapy.

CONCLUSION

Women with gestational trophoblastic disease who were registered late were significantly more likely to have normal levels of hCG and were less likely to need chemotherapy. A less intensive follow up may be justified in women with gestational trophoblastic disease who are registered with a normal hCG level.

Placental site trophoblastic tumor in a patient with brain and lung metastases

Placental site trophoblastic tumor is a rare neoplasm that arises from intermediate trophoblasts and shows diversity of biological behaviors, resulting in the absence of consistency in treatment modalities. A case of placental site trophoblastic tumor that extended to the cervix, with primary manifestation of amenorrhea and yellow foul-smelling vaginal discharge, is presented. Total abdominal hysterectomy was performed initially, and serial measurements of human chorionic gonadotropin levels were obtained. She was admitted with metastases to brain and lung 1.5 years after surgery. Combination chemotherapy (etoposide-methotrexate-dactinomycin/cyclophosphamide-vincristine) and radiotherapy were administered. There was no significant response to chemoradiotherapy. Despite changing chemotherapy regimen, she is still alive with progressive disease.

Tumeurs trophoblastiques gestationnelles

Placental site trophoblastic tumor and epithelioid trophoblastic tumor are rare gestational trophoblastic tumors. They both appear in the same context and follow the same course. We report two cases in patients aged 44 and 20 years. These lesions usually affect young women with a history of multiple gestations. Clinical manifestations include vaginal bleeding, uterine mass, and moderate elevation of serum beta human chorionic gonadotrophin levels. These morphologically distinct trophoblastic proliferations usually have a favorable course if complete excision is performed.

Role of surgery and radiation therapy in the management of gestational trophoblastic disease

Although sensitive human chorionic gonadotrophin (hCG) assays and advances in chemotherapy have assumed primary importance in the management of gestational trophoblastic disease (GTD), surgery and radiation therapy remain important in the overall management of patients. Management of molar pregnancies consists of surgical evacuation and subsequent monitoring. Hysterectomy may decrease the risk of post-molar trophoblastic disease. When incorporated into the primary management of malignant GTD, hysterectomy decreases chemotherapy requirements for patients with low-risk disease. Surgical intervention is frequently required to control complications of disease or as therapy to stabilize patients during chemotherapy. Salvage hysterectomy or other extirpative procedures may be integrated into the management of patients with chemorefractory disease. Interventional radiographical techniques are useful adjuncts to control haemorrhage from vaginal or pelvic metastases. Radiation therapy may also be combined with chemotherapy for the management of patients with brain metastases or, rarely, isolated metastases at other sites.

Placental site trophoblastic tumour

Placental site trophoblastic tumour (PSTT) is a very rare and unique form of gestational trophoblastic disease (GTD). This tumour represents a neoplastic transformation of intermediate trophoblastic cells that normally play a critical role in implantation. PSTT can occur after a normal pregnancy, abortion, term delivery, ectopic pregnancy or molar pregnancy. It displays a wide clinical spectrum, and when metastatic, can be difficult to control even with surgery and chemotherapy. Unlike other forms of GTD, PSTT is characterized by low beta-hCG levels because it is a neoplastic proliferation of intermediate trophoblastic cells. Expression, however, of human placental lactogen (hPL) is increased on histologic section as well as in the serum. The most common presenting symptoms of PSTT are vaginal bleeding and amenorrhoea. Diagnosis is confirmed by dilatation and curettage (D and E) and hysterectomy but meticulous evaluation of metastasis is mandatory. Most cases are confined to the uterus but pelvic involvement, lung and other organ metastasis has been reported. Unlike other forms of GTD, the WHO prognostic score is of little help. For the PSTT patient, surgery is the primary treatment of choice. For patients desiring future childbearing, D and C and adjuvant chemotherapy is an option. Because these tumours tend to be less sensitive than other types of GTD to chemotherapy, the most successful regimen to date has been with EMA/CO or EMA/EP. Good prognosis is anticipated in cases localized to the uterus, and when the interval between antecedent pregnancy and treatment is less than 2 years. In cases with distant metastasis or delayed treatment, the outcome is dismal. Advances in chemotherapeutic regimens have improved clinical reponse in metastatic disease.

Clinical aspects of gestational trophoblastic disease: A review based partly on 25-year experience of a statewide registry

BACKGROUND

Gestational trophoblastic disease is a fascinating group of pregnancy disorders characterised by abnormal proliferation of trophoblast, ranging from benign to malignant. Because the disease is uncommon, there is a need to formulate management with the assistance of collective information.

METHODOLOGY

A review of available information from English written literature was undertaken, especially data reported by registries around the world (Charing Cross Hospital in England, the North-western University and the New England area in the USA as well as our own experience in Queensland, Australia). Where possible, collated data from relevant studies were analysed to answer some of the questions posed in clinical practice, with reference to metastatic disease to liver and brain, twinning of molar gestation and coexisting fetus, and placental-site tumour.

RESULTS

We found that molar gestation can be classified according to its clinical presentation which influences the time taken to reach human chorionic gonadotropin (HCG) 'negativity' and the risk of persisting disease. Categorisation of risk is the basis for choice of chemotherapy to achieve good outcomes. Metastases to liver and brain remain problems in management; the development of 'new' metastases during chemotherapy is a very poor prognostic factor. In the variant of twinning with molar gestation and coexisting fetus, it is important to elucidate the fetal karyotype in planning management: a 69XXX fetus is not salvageable but a normal 46XX or 46XY fetus faces the prospect of early preterm delivery. The placental-site tumour is very rare; localised disease is curable by surgery; chemotherapy is less effective in disseminated disease. From collated worldwide data, the recurrence rate after one mole is 1.3% and after two or more is 20%. Reproductive outcome in subsequent pregnancies, even after multidrug chemotherapy, is not different from the general population. Because of the increased risk long-term of second tumours after multidrug chemotherapy a closer surveillance of these patients is necessary.

CONCLUSION

In general, the disease in its persisting or malignant form is 'a cancer model par excellence' because of an identifiable precursor condition, a reliable HCG marker, and sensitivity of the disease to cytotoxic drugs. With current management, retention of fertility is possible and normal reproductive outcome assured.

Extrauterine placental site trophoblastic tumour in association with a lithopedion

AIM

We describe an unusual case of extrauterine placental site trophoblastic tumour located in pouch of Douglas in association with a lithopedion.

METHODS AND RESULTS

A 35-year-old female presented with acute abdomen and peritonitis following rectal perforation. The patient gave a history of 5 months amenorrhoea followed by vaginal bleeding 5 years prior to admission. At laparotomy, a lithopedion was found in pouch of Douglas with rectal perforation and peritonitis. The lithopedion was removed, rectal perforation was sutured and a colostomy was performed. The colostomy was closed later and tumour was seen in the colostomy wound as well as attached to the lithopedion removed previously. The patient presented with a repeated episode of rectal perforation and the tumour had spread to colon, small intestine, omentum, mesentery and right ovary.

CONCLUSION

A high-grade malignant placental site trophoblastic tumour with aggressive clinical course occurred at an extrauterine site. It complicated calcified abdominal pregnancy and resulted in repeated rectal perforation and peritonitis.

Role of hysterectomy in management of gestational trophoblastic disease

OBJECTIVE

To evaluate incidence, indications, and outcome of hysterectomy in women presenting with gestational trophoblastic disease.

METHODS

A prospective observational study using a standardized protocol for registration, assessment, and treatment of gestational trophoblastic disease. A total of 5976 consecutive new patients registered between January 1986 and December 2000 with a diagnosis of gestational trophoblastic disease. The setting was a supraregional tertiary referral center for gestational trophoblastic disease.

RESULTS

Between January 1 1986 and December 31 2000, 5976 new patients with a diagnosis of gestational trophoblastic disease were registered at Weston Park Hospital, Sheffield. Of these patients, 301 required chemotherapy. Forty patients underwent hysterectomy. The average pretreatment risk score in women who had hysterectomy was 7.4. The mean time interval between diagnosis of molar disease and hysterectomy was 17 months. Indications for hysterectomy included uncontrollable vaginal or intraabdominal bleeding, localized chemo-resistant disease, and placental site trophoblastic tumor. In this group, 31 of 40 women had chemotherapy and 14 patients needed more than one regimen. These women were also more likely to have atypical histology (3 invasive moles, 6 placental site trophoblastic tumours, 13 choriocarcinomas, and 2 dimorphic tumours). There were 10 deaths in all registered patients with molar disease and 4 of these were in the hysterectomy group.

CONCLUSION

Hysterectomy was performed in 1 in 150 northern UK women with gestational trophoblastic disease. Patients needing hysterectomy represent an increased-risk group as indicated by their high pretreatment risk scores, atypical histology, frequent use of salvage chemotherapy, and higher mortality.

Successful management of metastatic placental site trophoblastic tumor with multiple pulmonary resections

INTRODUCTION

Placental site trophoblastic tumor (PSTT) is an uncommon variant of gestational trophoblastic disease. Most of these tumors are confined to the uterus and treated with a simple hysterectomy. However, 30% of these patients will present with metastatic disease. These patients are typically treated with a hysterectomy followed by adjuvant multiagent chemotherapy. Unfortunately, PSTT is relatively resistant to chemotherapy when compared to other forms of gestational trophoblastic disease. Consequently, these patients have a poor prognosis.

CASE

We present a case report of a 26-year-old female with multiple metastatic lesions to the lungs unresponsive to chemotherapy who was managed with multiple pulmonary resections. She has remained clinically free of disease at 28 months of follow up.

CONCLUSION

A patient with metastatic PSTT was successfully managed with radical surgical resection of chemotherapy-resistant sites.

Placental site trophoblastic tumor (PSTT) in mother and child: first report of PSTT in infancy

BACKGROUND

To the authors' knowledge, placental site trophoblastic tumors occurring simultaneously in mother and infant have not previously been reported.

PROCEDURE

The clinicopathologic features of metastatic placental site trophoblastic tumor in a mother and her 4-month-old son are described.

RESULTS

The disease in the infant was aggressive, and he died in multiorgan failure within 5 weeks of hospital admission. Autopsy showed widespread metastases to liver, lungs, pleura, kidney, mesentery and lymph nodes. The mother, who had a uterine tumor and lung metastases, was treated with chemotherapy and hysterectomy and has no evidence of disease 26 months post-treatment.

CONCLUSIONS

This report shows that placental site trophoblastic tumors can metastasize in both mother and child.