Postoperatively, the patient had a prolonged febrile complication with an abscess in the right pelvic fossa treated with antibiotics and then by a trans-abdominal CT guided drainage placing.
Soon after hysterectomy, beta-HCG values started to decrease rapidly from 10,272 mUI/mL, on the day before the surgery, to a negative value of 30 mUI/mL after 4 weeks. Furthermore, 3 weeks after surgery the fever went down to normal. The patient is now after a 3 years clinical and laboratory follow-up, with constant negative serum beta-HCG levels.
3 Case report 2
A 43-year-old woman, para 1/0/3/1 (1 caesarean, 2 previously induced abortions, 1 miscarriage), with a previous smoking habit. Four years ago, she underwent a mammographic screening that revealed a suspected nodule for breast cancer. The following echo-guided biopsy showed a low-intermediate grade ductal breast cancer with a 100% positivity for both estrogen and progesterone receptors that required a therapy based on tamoxifen and luteinizing hormone-releasing hormone analogues.
Five years after the last pregnancy, a miscarriage, a routine trans-vaginal ultrasound revealed a suspicious endometrial thickness in the medium third of the uterine cavity, measuring 4.5 mm, negative at the Color-Doppler evaluation, without myometrial invasion. Although, the remnant endometrium appeared regularly thin (Fig. 7A–C).
A subsequent hysteroscopic guided biopsy unveiled the presence of PSTT, positive for Cytokeratin pool (CK pool), but negative for beta-HCG and protein 63. Serum oncological markers (Carbohydrate Antigen 15.3; Carbohydrate Antigen 125; Carbohydrate Antigen 19.9; Carcinoembryonic antigen and beta-HCG) were all negative. Furthermore, the total body contrast medium CT-scan showed a negative result ruling out distance metastasis, pelvic organs enlargements or ascites (Fig. 8).
In order to pursue the patient's request for surgery, after a comprehensive counseling, we performed a total extra-fascial hysterectomy with bilateral salpingo-oophorectomy and an extensive adhesiolysis, because of the presence of many fibrous adhesions. No bulky lymph nodes were detected at the digital examination of the pelvic and lombo-aortic retroperitoneum.
The final histological examination (Fig. 9) confirmed the diagnosis of a minimally invasive PSTT of the uterus, sharing some features with the PSN, whereas the cervix, the fallopian tubes and the ovaries were all negative. Moreover, immunohistochemistry revealed the following results: CK pool positive, Ki67 index < 5%, beta-HCG negative and protein 63 negative.
In the end, there were no post-operative complications and the clinical-laboratoristic follow up (conducted for respectively for 4 years and 15 months) has been negative for both breast cancer and PSTT-PSN until now.
PSTT is a very rare malignant tumor that belongs to a family of pregnancy-related diseases. Less than 300 cases of PSTT have been reported in literature,[3,4] with an incidence of ≈ 1/50,000–100,000 pregnancies representing only the 0.23% to 3.00% of all GTDs.[1,2,5] It derives from an improper fertilization based on the duplication of paternal chromosomes and the loss of the maternal ones. Therefore, an imbalanced karyotype-control mechanism determines aneuploidies or rearranged diploidies leading to an impaired differentiation of the trophoblast.
Our report describes 2 additional cases of PSTT: the first derived from a persistent grade I hydatidiform mole, whereas the second one originated 5 years after a miscarriage. A Medline Literature Analysis of PSTT revealed that, in order of prominence, PSTT often follows a normal term pregnancy (61% of cases). Therefore, cytogenetic studies demonstrated that PSTTs are mostly diploid instead of aneuploid. However, a molar pregnancy is present in 12% of PSTTs, a miscarriage in 9%, induced abortion in 8%, whereas a percentage of 3% is represented by ectopic pregnancies, stillbirths or preterm deliveries. The remnant percentage (7%) waits to be unveiled. Since the complete variant of HMs (hydatidiform moles) becomes a GTN in 15% to 20% of the cases, it can be considered a pre-malignant lesion. On the contrary, only 0.5% to 2% of the partial moles could evolve into malignant tumors. More than two-thirds of complete HMs have a diploid genome (46, XX) arising from the duplication of the haploid genome of a single sperm fertilizing an ovum, without maternal chromosomes already lost during meiosis. By contrast, partial hydatidiform moles are usually triploid, because of the fertilization of an apparently normal ovum by 2 sperms or occasionally a diploid sperm. The ultrasound examination of our first case (see Fig. 1) showed pathological trophoblastic structures and an intrauterine fluid collection without any yolk sac nor embryo that led to the initial hypothesis of a complete HM. Whereas the second one emerged 5 years after a miscarriage without any imaging or histological signs of vesicular mole.
Recently, some risk factors for GTNs have been recognized as hormonal dysfunctions, such as a late menarche, the usage of oral contraceptives and light menstrual flow. Notably, both the patients under our observation had a smoking habit and the second one was under hormonal therapy for a previously diagnosed breast cancer (tamoxifen and luteinizing hormone-releasing hormone analogues). Furthermore, the first case of PSTT came from a persistent HM with high values of serum beta-HCG, whereas the second one took origin 5 years after a miscarriage with negative serum beta-HCG essay but sharing borderline features between PSTT, malignant, and PSN, benign.
Moreover, the primary tumor site is nearly always located in the fundus or the corpus of the uterus, as respectively seen in our cases. Notwithstanding, 4 cases of cervical location have been described in literature[4,11–15] probably after an ectopic cervical pregnancy or by the transport of cancer cells from a PSTT of the corpus that later underwent a silent regression.
PSTT origins exclusively from the proliferation of the intermediate interstitial trophoblast lacking the syncytiotrophoblast's population. Therefore, it is characterized by peculiar histological elements because of the absence of villi, creating locally infiltrating nests and monomorphic sheets with a modest pleomorphism and a mild mitotic activity. Due to the absence of the syncytiotrophoblast cells, PSTT expresses a lower level of serum beta-HCG than CC so resulting possibly negative during laboratory tests, as in our second case.
From a pathological point of view, the proliferation of the intermediate trophoblastic cells evolves from the implantation site-like trophoblast nodule, which infiltrates the smooth muscle cells of the decidual spiral arterioles, to a lesion characterized by necrosis and hemorrhage. Vaginal bleeding and/or amenorrhea represent the usual presentation, as in our first case. The PSTT's growth covers a time period of weeks or even years, as respectively in our cases. A recent case series reported a median time from antecedent pregnancy to diagnosis of 12 months (range 0–240). Sometimes, PSTT manifests with preeclampsia, beta-HCG triggered hyperthyroidism, unspecific symptoms, such as nausea or hemoptysis, enlargement of the uterus, lutein-cysts of the ovaries. Surprisingly, none of these characteristics emerged from the second case that was diagnosed only after a routine ultrasound exam followed by a hysteroscopic biopsy.
Usually, the value of serum beta-HCG does not reflect properly the tumor load in PSTTs leading to false-negative results.[7,20] This marker could be negative, as in our second case, since the cancer-related beta-subunit of HCG can exist in many different forms and fragments such as nicked free beta, c-terminal peptide, beta-core and hyperglycosylated form. By contrast, immunohistochemistry usually shows Human Placental Lactogen (HPL), an extravillous trophoblast marker on surgical specimens, even though it is rarely detectable in serum.[7,10] Thence, the endometrial tissue evaluation of HPL may become a useful diagnostic instrument in case of initial stage of PSTT after a hysteroscopic biopsy or D&C. In the first case, this could have been useful to distinguish the persistent mole from the area of PSTT transformation, but it was not available. In summary, the immunohistochemical analysis of PSTT usually shows the features described in Table 1.[4,21,22]
Nowadays, the instrumental diagnosis relies mainly on transvaginal ultrasound that tends to highlight some features shared by GTNs, such as echogenic and vascular masses detectable also with echo-color Doppler, involving the endometrium and eventually deepening into the myometrium. Furthermore, GDTs are characterized by a wide range of ultrasound findings, such as a thickened endometrium (ie, our second case), a discrete mass with or without the classical echogenic and vascular enlargement containing clusters of little cysts, as in our first case, characterized by a coexistence between PSTT and a persistent hydatidiform mole. Molar diseases usually differ from PSTT because of the depth of trophoblastic invasion within the myometrium, as we detected in our first case. Recently, a Chinese study has classified the sonographic presentation of PSTT into 3 types, using a transvaginal probe: type I, heterogeneous solid mass in the uterine cavity with a degree of vascularization on color Doppler imaging from minimal to moderate; type II, heterogeneous solid mass deepening in the myometrium and coexisting with a degree of vascularization from minimal to high; type III, cystic lesions within the myometrium with a high degree of vascularization (lacunar-type lesions). According to Zhou Y et al, our first case could be classified as a type II (see Fig. 1), whereas our second case is partly classifiable as type I, because the heterogeneous solid mass in the uterine cavity was completely negative at color Doppler examination (Fig. 7B).
The presence of myometrial invasion can be confirmed using dedicated pelvic T1 and T2 weighted magnetic resonance imaging and it appears, respectively, hypointense and hyperintense with disruption of the junctional zone. Whenever PSTT origins from a molar pregnancy, it could be evidenced as an enhancing multicystic tissue characterized by vascular structures within the enlarged uterus.[24–26]
For staging assessment, total body CT and contrast dye may be substituted by 18-fluorodeoxyglucose positron emission tomography CT-scan, especially for lung metastasis.[27,28] Furthermore, PSTT could be partly scored according to the anatomical staging as in International Federation of Gynecology and Obstetrics (FIGO) 2000 (see Table 2),[7,9] because there is no mention of the tumor's lymphatic spread. According to us, the FIGO 2000 score should consider other unclassified stages with/without a pelvic and/or abdominal lymph nodes involvement. Moreover, PSTT should not be classified using the scoring system for GTN as in FIGO 2000 based on prognostic factors, (see Table 3), but it still requires its own staging. Some authors declare that a common prognostic scoring system, as well as the other GTNs (see Table 3), could be useful to manage and compare data between different hospitals,[16,29] even though it has been mostly realized for malignant gestational tumors deriving from villi, namely invasive molar disease and CC.
In our decision-making process, we set a based on literature flowchart (see Fig. 10) to rule out the presence of poor prognosis factors that can be outlined by the following conditions[4,21,22,30–34]: a long-time interval since the last pregnancy, in particular ≥ 48 months[21,30] or even ≥ 24 months (P = .014); age over 35 years (P = .025); a high mitotic index, described as more than 6 mitosis in median mitotic count per 10 high-power fields, (P = .005); the presence of cells with clear cytoplasm (P < .0005); a vascular invasion; a deep myometrium invasion (P = .006); an invasion of the serous membrane; extensive coagulative necrosis (P = .024); persistence of high post-operative beta-HCG levels and, more generally, a maximum HCG level > 1000 mIU/mL (P = .034); FIGO stage III or IV (P < .0005).[4,21,22,30–34]
However, we tried also to use the prognostic FIGO/World Health Organization (FIGO/WHO) score (Table 3) with a final score of 1 for the first case and 3 for the second one, determining a low-risk value (< 6) in both. In details, the first case had just 1 poor prognosis factor, because the patient was 37 years old (so, more than 35). Despite this, there were many other good prognosis factors, such as myometrium deepening for less than 50%, the presence of a mild proliferation index, previous and concomitant molar ongoing pregnancy. Moreover, the value of beta-HCG dropped significantly after the surgery until reaching negative essays in about a month and remaining stable during the further follow-up. Our second case was managed considering the prevalence of good prognosis factors, the previous diagnosis of breast cancer and the older age (43 years old), by performing a hysterectomy with bilateral adnexectomy. Moreover, its proliferation index was very low, and the myometrial invasion was unclear, quite undetectable, with a diagnosis of minimally invasive PSTT as it shared many features with PSN at the final histology. Therefore, we decided not to consider the long interval since the last pregnancy, even though it is a pillar criterion for the prognosis of a pure PSTT. PSN may be detected several months or years after the pregnancy itself representing a sort of intermediate trophoblast remnants with a benign behavior. The PSN does not require any treatment once removed because it cannot develop a recurrence.
Concerning the treatment of PSTT, the mainstay is a primary hysterectomy with the sampling of suspicious pelvic-abdominal lymph nodes or lymphadenectomy and ovarian conservation, unless there is a family history of ovarian cancer or the patient is post-menopausal.[7,17,22,30] Most of the authors recommend a lymph node sampling because PSTT has a significant tendency to metastasize through lymphatic vessels.[4,7] Precisely, in the 5.9% of PSTTs there are lymphatic metastases at the time of the diagnosis or the recurrence. In our cases, we did not perform lymphadenectomy or lymph node sampling because the pre-operative ultrasound assessment of the myometrium invasion was less than 50% in the first case and barely undetectable in the second one. According to some authors, these additional surgical procedures could prominently fit for stage I PSTT in presence of risk factors such as a myometrium invasion > 50%, as well as in all cases of stage II. It is still unknown whether a complete abdominal and pelvic lymphadenectomy could influence the overall survival.
Patients with risk factors, such as a high mitotic rate or metastatic disease, will need a multi-agent adjuvant chemotherapy, either EP/EMA (etoposide and platinum alternating with etoposide, methotrexate/folinic acid rescue, actinomycin-D) or TE/TP (paclitaxel, cisplatin/ paclitaxel, etoposide).[7,20,21]
In both our cases, we avoided lymph node surgery and the adjuvant chemotherapy because the good prognostic factors outweighed the poor ones as recommended by the newest (2013) guidelines of the European Society for Medical Oncology.[3,7] Therefore, they started a follow up with periodic serum oncological markers, comprising beta-HCG test, imaging studies and clinical evaluation.
In clinical stage I without poor prognostic factors, in case of strong hope for future childbearing, the patient might undergo a fertility-sparing surgery, even with a minimally invasive approach, such as: uterine evacuation using US-guided procedures to avoid uterine perforation, hysteroscopy resection and combined hysteroscopic/laparoscopic resection. Another way to perform a local uterine resection is a laparotomy with the modified Strassman approach, characterized by a success percentage of 20%, although this choice of treatment requires further evaluations.[36,37] However, this fertility-sparing and minimally invasive treatment should be considered only experimental, carrying the possibility to miss microscopic multifocal uterine disease or disseminating disease, compromising the overall survival in the end. Undoubtedly, the patient must be aware of the possible risk of recurrence, missed micro-metastasis, tumor seeding, partial resection and of the eventual salvage hysterectomy for inadequate or involved resection margins. This could be possibly avoided with the assessment of intra-operative frozen sections or for beta-HCG post-operative increase associated with a myometrium infiltration.[4,37]
Generally, the PSTT has a good prognosis when diagnosed at the first stage (Table 3; Fig. 10), which is mainly treated with surgery. However, extra-uterine disease leads to a poor outcome also because the PSTT is less responsive than other GTNs to the conventional chemotherapy based on methotrexate or actinomycin-D, for instance, EMA/CO. Unfortunately, PSTT is characterized by a 61% resistance or incomplete response to chemotherapy agents. Nevertheless, Swisher and Drescher reported a complete response to EMA/CO in a patient with lung and vagina metastasis and in 2 of their 7 cases of PSTT. High-risk patients will need adjuvant chemotherapy, a multi-agent platinum-based regimen lasting for 8 weeks of normal HCG levels, such as the most common EMA/EP[10,21,22] or the combination TE/TP.[7,10,22] Notwithstanding the high rate of cure, a substantial number of patients have recurrent disease and the main discriminator for survival and recurrence is a time-period of 48 months since the antecedent pregnancy. In case of recurrence, the following outcome for patients with PSTT is worse than other forms of GTD because the former can gain a long-term remission in only a third of cases (precisely 33%), whereas the latter points up to 75% to 90% with second-line treatment.
PSTT is a rare and peculiar type of tumor that can result demanding for its identification because it could be misdiagnosed as other forms of GTDs. Although the uniqueness of our work resides in the extreme rarity of the PSTT itself, this might represent at the same time a limitation because our evaluations may not easily be generalized. Our first case had a difficult diagnosis because the tumor was synchronous to a hydatidiform mole and the first D&C missed the presence of PSTT. The subsequent clinical evolution led the medical team and the patient to decide for major surgery. Notably, PSTT can also be thought of during a routine examination in case of suspicious endometrial area evaluated firstly with ultrasound and then with a hysteroscopically-guided biopsy in patient with a history of deliveries or miscarriages.
Form a clinical point of view, we should always perform a complete physical examination and collect the clinical history (age, reproductive history, amenorrhea, enlarged uterus more than gestational age, vaginal bleeding, metastasis signs). These data are extremely helpful to guide the diagnosis process and to define the prognosis. Even with some limitations, testing the value of serum beta-HCG could be helpful as a follow-up marker, as in our first case.
Among the imaging techniques, intravaginal Doppler ultrasound examination plays a key role to localize and hypothesize the malignant nature of the lesion with the help of Zhou Y et al classification. If performed by an expert, it can predict also the stage of the disease evaluating the local invasion. To complete the assessment of the staging and the prognostic risk, we suggest also a CT-scan.
Whether the good prognostic factors overweight the poor ones and the childbearing desire has already been accomplished, as in our cases, the main treatment remains extra facial total hysterectomy. In analogue cases as ours, but with a strong desire for pregnancy, a conservative surgical approach may be used. Once the reproductive purpose is achieved, the patient needs to undergo a strict clinical follow-up and a further surgical re-evaluation.
Thanks to all the authors.
Conceptualization: Matteo Loverro.
Data curation: Rosalba De Nola, Luca Maria Schönauer, Maria Grazia Fiore, and Edoardo Di Naro.
Investigation: Rosalba De Nola, Luca Maria Schönauer, Carmine Carriero, and Edoardo Di Naro.
Methodology: Rosalba De Nola.
Project administration: Rosalba De Nola.
Supervision: Matteo Loverro, Edoardo Di Naro.
Writing – original draft: Rosalba De Nola.
Writing – review and editing: Rosalba De Nola, Matteo Loverro.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
beta-HCG; gestational trophoblastic disease (GTD); placental site nodule (PSN); placental site trophoblastic tumor (PSTT); pregnancy