Diagnosis and Management of Mixed Gestational Trophoblastic Neoplasia: A Study of 16 Cases and a Review of the Literature

Postmenopausal mixed gestational trophoblastic neoplasia with complete response to immunotherapy - A case report

•Mixed GTN.•GTN in a post-menopausal woman.•Treatment of GTN with immunotherapy.

Special epithelioid trophoblastic tumor: A case report

BACKGROUND

Epithelioid trophoblastic tumor (ETT) is a special type of gestational trophoblastic tumor. However, its pathogenesis has been incompletely elucidated. ETT rarely occurs in the ovaries and fallopian tubes, unlike placental site trophoblastic tumor, requiring a histopathological biopsy and immunohistochemistry for further diagnosis.

CASE SUMMARY

A 29-year-old woman with irregular vaginal bleeding and elevated serum chorionic gonadotropin (β-hCG) levels presented similar symptoms to ectopic pregnancy. Transvaginal ultrasound revealed abnormal echoes of the left adnexa. Postoperatively, the pathology of the left ovary and fallopian tube was reported as ETT. The patient was followed up with regular hCG measurements and ultrasounds. The blood hCG values showed an upward trend 3 mo after the operation and then chemotherapy was prescribed. The current health status is normal.

CONCLUSION

For women of childbearing age with elevated serum β-hCG levels, practitioners should consider ETT and be alert to the poor prognosis of the disease. After surgery, the patient's condition should be closely observed to prevent recurrence and metastasis. Postoperative chemotherapy is only helpful for treating the disease to a certain extent.

Effectiveness and Safety of Toripalimab Combination Therapies for Patients With Chemo-Resistant Choriocarcinoma

Toripalimab as a novel PD-1 inhibitor has presented its promising efficacy in patients who developed chemo-refractory carcinomas, whereas no study has ever investigated the effectiveness of toripalimab in chemo-resistant choriocarcinoma. Here we reported the effectiveness and safety data of 4 patients with chemo-resistant choriocarcinoma who underwent PD-1 antibody therapy by toripalimab and individualized chemotherapies. From January 2019 to August 2020, 4 patients with choriocarcinoma were admitted in Shengjing Hospital of China Medical University. The patients’ age ranged from 29 to 52 years with a median of 36 years. All the patients achieved CR after the combined therapy of toripalimab with individualized chemotherapies according to the decreased serum β-hcg level. Two of the four patients were observed with treatment-related adverse events (AEs), including one grade I skin rash and one grade I pruritus. Our cases showed that toripalimab combined with chemotherapy presented a tolerable safety profile and promising effectiveness in patients with chemo-resistant choriocarcinoma, indicating its potential as salvage therapy for this subset of patients.

Coexisting Epithelioid Trophoblastic Tumor and Placental Site Trophoblastic Tumor During Asymptomatic Relapse: A Case Report and Literature Review

Gestational trophoblastic neoplasms are a group of trophoblastic tumors that include choriocarcinoma (CC), epithelioid trophoblastic tumors (ETTs), and placental site trophoblastic tumors (PSTTs). Mixed gestational trophoblastic neoplasms include combinations of CCs with ETTs and/or PSTTs; combinations of ETTs and PSTTs have also been described. This report describes the case of a 49-yr-old female with mixed ETT and PSTT discovered due to menstrual delay and a positive beta-human chorionic gonadotropin in serum 11 yr after normal pregnancy; it is an asymptomatic recurrence of the neoplasm after 2 yr. Moreover, only the ETT recurred without evidence of PSTT by biopsy and without any increase in human chorionic gonadotropin levels, even though human chorionic gonadotropin was positive in the first onset of the disease. We also reviewed published English literature, which revealed that there are only 36 cases of mixed trophoblastic tumors to date, of which pure mixed ETT and PSTT were reported only in four cases including our case. The most common combination is CC admixed with an ETT (52%), followed by CC with PSTT in 30.5%. CC admixed with an ETT and/or PSTT account for 83% of the cases, of which pure mixed ETT and PSTT were reported only in 4 cases (11%). The rarity of this condition entails reporting of all cases to facilitate future research and clinical management.

Diagnosis and management of a metastatic mixed gestational trophoblastic neoplasia with synchronous primary lung cancer

Mixed gestational trophoblastic neoplasias (GTNs) are rare placental tumours that arise from abnormal fertilisation events. To date, only 34 patients with mixed GTNs have been reported in the literature. As such, the management of such cases remains challenging. This report presents a case of a mixed GTN that was further complicated by a synchronous primary lung adenocarcinoma. Our patient was initially treated with hysterectomy, with surveillance labwork showing persistence of her malignancy. She then began combination chemotherapy, at the end of which she appeared to be in remission clinically. Unfortunately, subsequent imaging showed the persistence of pulmonary nodules that were ultimately resected, demonstrating a new primary lung adenocarcinoma. At present, she remains free of both cancers 2 years after her initial diagnosis. The complexity of this case underscores the importance of patient-centred treatment for rare tumours and the role of a multidisciplinary team in the effort to provide holistic care.

Pathology of gestational trophoblastic disease (GTD)

Gestational trophoblastic disease (GTD) is subclassified into hydatidiform mole (HM), gestational trophoblastic tumours (GTT) and non-neoplastic trophoblastic lesions. HM, partial and complete, originate from villous trophoblast and are considered as preneoplastic conditions. The risk for the development of persistent GTD, mostly as invasive HM, ranges from 0.5% to 20%, which depends on the type of molar pregnancy. The risk of development of trophoblastic tumour after PHM is <0.5% and 2%-3% after CHM. GTT represent a spectrum of neoplasms that originates from the intermediate, largely extravillous, trophoblast and these include choriocarcinoma (CC), placental site trophoblastic tumour (PSTT), epithelioid trophoblastic tumour (ETT) and mixed trophoblastic tumour. Among tumour like conditions, exaggerated placental site reaction (EPSR) and placental site nodule (PSN) (s)/plaque (s) are included. The morphological appearances of HM can be mimicked by abnormal (non-molar) villous lesions, and similarly, GTT can be mimicked both by non-malignant tumour-like conditions and non-gestational tumours with trophoblastic differentiation, which add to the diagnostic dilemma of these rare conditions. GTT have a favourable prognosis and better response to specific chemotherapeutic regimens when compared with non-gestational malignant genital tract neoplasms. The correct diagnosis and classification of these rare conditions are therefore important. This article focusses on the morphological appearances, immunocytochemistry as an aid in the diagnosis and the changes in current WHO classification of GTDs (WHO 2020).

Placental site trophoblastic tumour and epithelioid trophoblastic tumour

Placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT) are the rarest subtypes of gestational trophoblastic disease (GTD). Their diagnosis is complicated and lacks specific and sensitive tumour markers. They are slow-growing tumours and can occur months to years after any type of antecedent pregnancy. The primary treatment for localised disease is hysterectomy. However, extra-uterine invasion and/or metastasis occur in about one-third of cases and still cause death in a small number. Most patients are young; hence, fertility preservation is a consideration. The major obstacle for prognosis is chemotherapy resistance. The current understanding of these tumours remains elusive and no randomized controlled trials have been done. Even those centres treating a large number of patients with GTD will infrequently manage PSTT/ETT. In this review, we assess progress in the understanding of the disease and discuss four main clinical challenges - establishing conformity of practice, devising a risk-adapted approach to clinical management, establishing long-term follow-up data and evaluating therapies for poor prognosis and multi drug-resistant patients.

Stage IV choriocarcinoma in a 47-year-old-woman 12 years after her last known pregnancy: A case report

INTRODUCTION

Choriocarcinoma is a rare, invasive, gestational trophoblastic disease that secretes high levels of beta human chorionic gonadotropin (BhCG) and is thought to affect 1 in 40,000 pregnancies. We present a rare case of metastatic choriocarcinoma.

CASE PRESENTATION

A 47-year-old woman presented with shortness of breath, anemia and an elevated serum BhCG level. Her most recent known pregnancy was 12 years previously. Following investigation, she was found to have FIGO stage IV choriocarcinoma with brain metastasis, despite having not experienced any abnormal vaginal bleeding. She was treated with chemotherapy; her treatment was complicated by neutropenic sepsis and a visceral perforation. The patient went into remission and received long-term follow-up.

DISCUSSION

It is unclear in this case whether the disease occurred following a pregnancy 12 years previously and was never detected or whether it was due to a recent unknown pregnancy or a non-gestational cause. Increased awareness of this condition will allow timely diagnosis, prompt management and improved prognosis. Following diagnosis, determination of BhCG levels is essential for monitoring and guiding treatment and a multidisciplinary approach should be taken towards care.