Ovarian non-gestational placental site trophoblastic tumor with lung metastasis: further evidence for a distinct category of trophoblastic neoplasm

We previously described a series of cases which characterize a distinct group of primary ovarian placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT) as a non-gestational set consistent with germ cell type/origin. Here we report a new case of ovarian non-gestational PSTT. The patient was a 13 year-old young female admitted for a spontaneous pneumothorax of the left lung. The pathology of lung wedge excision specimen demonstrated metastatic PSTT and ovarian biopsy showed atypical intermediate trophoblastic proliferation which was found to be PSTT in the subsequent salpingo-oophorectomy specimen. In the ovary, the tumor was composed of singly dispersed or small clusters of predominantly mononuclear cells and rare multinucleated cells extensively infiltrating the ovarian parenchyma, tubal mucosa, and paraovarian/paratubal soft tissue. A minor component of mature cystic teratoma (less than 5% of total tumor volume) was present. Immunohistochemically, the neoplastic cells of main tumor were diffusely immunoreactive for hPL, Gata3 and AE1/AE3, and had only rare hCG-positive or p63-positive cells. The morphology and immunohistochemical results support a PSTT. Molecular genotyping revealed an identical genotype pattern between the normal lung tissue and the metastatic PSTT, indicating its non-gestational nature of germ cell type/origin. This case represents the first case of such tumor with distant (lung) metastasis. This case also provides further evidence to support our recommendation that primary ovarian non-gestational intermediate trophoblastic tumors of germ cell type/origin, including PSTT and ETT, should be formally recognized in classification systems.

The Role of Surgery in Gestational Trophoblastic Disease

Fifty-eight consecutive patients with malignant trophoblastic tumors of gestational origin were treated at the 1st Department of Obstetrics and Gynecology of the University of Milan between 1975 and 1981. Thirty-five (60.3%) of the patients were treated with combined surgery and chemotherapy. Of these, 44.8% had genital surgery, 12% extragenital surgery, and 5.1% had emergency laparotomies. Minor surgery was done to 17.1% of the patients. Five patients (20.8 %) with tumors limited to the uterus and treated with chemotherapy only became drug-resistant, whereas 3 patients (9%) later developed lung metastases. All the patients are alive without any clinical signs of the disease. When there were metastatic tumors, the survival of the group first submitted to a « debulking » operation of the primary focus was 80%, and the survival of the group treated only with chemotherapy was 78.5%. Seven cases required extragenital surgery for the indications discussed in detail and because they had measurable HCG. Six of these had thoracotomies and one had a craniotomy. Five of the 6 patients who underwent thoracotomy (83.4%) had a complete remission. Chemotherapy remains the treatment of choice for trophoblastic tumors. Nevertheless, our data confirm that for some cases, mostly in the high risk group, complete eradication cannot be obtained with antitumor agents. Adjuvant surgery of carefully selected patients helps to save some of those who no longer respond to chemotherapy.

Case report of pulmonary epithelial trophoblastic tumor in a young female patient

INTRODUCTION

An epithelial trophoblastic tumor (ETT) is a kind of rare trophoblastic tumor that may have the correlation with a prior gestational event. Especially, the one that appears in the lung is extremely rare.

CASE SUMMARY

Here, we present a 24-year-old female patient with the chief complain of vaginal bleeding for more than 1 month, who was found to have a large mass (7.5 × 4.5 cm) in the right lower lobe, and it was finally confirmed as lung ETT by postoperative pathology after a successful radical resection of the pulmonary lobe.

CONCLUSIONS

As the reason of an extreme rare occurrence of the ETT, doctors can easily misdiagnose the disease. When the patient was found to have a mass with irregular vaginal bleeding and a high level of beta-human chorionic gonadotropin, we need to consider ETT. Currently, surgery is still the most effective method.

Coexisting epithelioid trophoblastic tumor and placental site trophoblastic tumor of the uterus following a term pregnancy: report of a case and review of literature

Gestational trophoblastic neoplasms are a group of fetal trophoblastic tumors including choriocarcinomas, epithelioid trophoblastic tumors (ETTs), and placental site trophoblastic tumors (PSTTs). Mixed gestational trophoblastic neoplasms are extremely rare. The existence of mixed gestational trophoblastic neoplasms that were composed of choriocarcinoma and/or PSTT and/or ETT was also reported. Herein, we present a case of uterine mixed gestational trophoblastic neoplasm which is ETT admixed with PSTT, and reviewed 9 cases of mixed gestational trophoblastic neoplasms reported in English literature available. The most common combination was a choriocarcinoma admixed with an ETT and/or PSTT. Mixed gestational trophoblastic neoplasms present in women of reproductive age and rare in postmenopausal, Abnormal vaginal bleeding is the most common presenting symptom, serum β-HCG levels are elevated, mostly below 2500 mIU/ml, the tumor was limited to uterus in 7 cases, the rest of 3 with pulmonary metastases at the time of diagnosis. Mixed gestational trophoblastic neoplasms have more similar clinical features with intermediate trophoblastic tumors (ITTs). Total hysterectomy with lymph node dissection is recommended treatment for mixed gestational trophoblastic neoplasms, and chemotherapy should be used in patients with metastatic disease and with nonmetastatic disease who have adverse prognostic factors.

Diagnostic challenges in cornual epithelioid trophoblastic tumor

OBJECTIVE

We present a case of primary cornual epithelioid trophoblastic tumor (ETT) because of its rarity and diagnostic and therapeutic challenge.

CASE REPORT

A 28-year-old woman, gravida 1, para 1, who missed menstruation for 3 months, had an elevated β-human chorionic gonadotropin serum level of 2764 mIU/mL, an absence of intrauterine pregnancy, and the presence of an adnexal mass detected by transvaginal ultrasound. As an ectopic pregnancy was suspected, laparoscopic surgery was performed and showed a right corneal mass. Complete excision of the tumor was done through exploratory laparotomy. Frozen pathology favored the diagnosis of squamous cell carcinoma. Since there was no apparent tumor at other sites, no additional surgery was done. The final pathology showed ETT. Primary ETT is often misdiagnosed as an ectopic pregnancy, leading to delayed treatment, and poses a diagnostic challenge in distinguishing it from squamous cell carcinoma during pathological examination.

CONCLUSION

Careful evaluation and avoidance of overtreatment are emphasized.

Decidual endovascular trophoblast invasion in women with polycystic ovary syndrome: an experimental case-control study

CONTEXT

Previous experimental and clinical data suggest impaired decidual trophoblast invasion in patients with polycystic ovarian syndrome (PCOS).

OBJECTIVE

The objective of the study was to test the hypothesis that decidual endovascular trophoblast invasion in pregnant patients with PCOS is impaired and to clarify the potential mechanisms involved.

DESIGN

This was an experimental case-control study.

SETTING

The study was conducted at the academic Departments of Obstetrics and Gynecology and the Unit of Pathology (Italy).

PATIENTS

Forty-five pregnant subjects screened from a wide population of women waiting for legal pregnancy termination were included in the final analysis. Specifically, 15 pregnant patients with PCOS were enrolled as cases and another 30 age- and body mass index (BMI)-matched healthy pregnant women without any feature of PCOS were enrolled as the controls.

INTERVENTION

Interventions included the collection of trophoblastic and decidual tissue at the 12th week of gestation.

MAIN OUTCOME MEASURES

Clinical, ultrasonographic, and biochemical data as well as the histological analysis of decidual endovascular trophoblast invasion.

RESULTS

The rate of implantation site vessels with endovascular trophoblast invasion (ratio between total number of implantation site vessels and total number of vessels with endovascular trophoblast invasion) and the extent of endovascular trophoblast invasion (proportion between immunoreactive areas to cytokeratin 7 and to CD34) were significantly lower in patients with PCOS compared with healthy non-PCOS controls. Endovascular trophoblast invasion data were significantly and indirectly related to the markers of insulin resistance and testosterone concentrations in PCOS patients.

CONCLUSIONS

Pregnant patients with PCOS patients have impaired decidual trophoblast invasion. Further studies are needed to evaluate the exact mechanisms through which insulin resistance and hyperandrogenemia exert this effect.

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of beta-human chorionic gonadotropin (beta-hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low-resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2-year remission, a low rise in serum beta-hCG was observed. Transvaginal ultrasound revealed a well-circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental-site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers.

Cytologic findings of epithelioid trophoblastic tumor of the uterus: a case report

BACKGROUND

Epithelioid trophoblastic tumor (ETT) is a rare entity within trophoblastic tumors. It is difficult to recognize ETT because of its epithelioid appearance.

CASE

A 35-year-old female, 5 years after pregnancy, experienced genital bleeding 2 months prior to consulting us. Preoperative laboratory data showed a slightly elevated serum level of human chorionic gonadotropin (hCG). A cytologic cervical smear revealed large, polygonal, atypical cells. These cells had mononucleate, ovoid, irregularly enlarged and hyperchromatic nuclei with 1 or 2 conspicuous nucleoli. The cytoplasm was thin and abundant, with a distinct cell membrane, and sometimes showed vacuolation. The patient was diagnosed with uterine cancer, and hysterectomy was performed. The tumor was present in the uterine corpus, measuring 3 x 2.5 x 2.5 cm. Histologically, it was composed of mainly mononuclear tumor cell nests resembling intermediate trophoblastic cells with zones of hyaline material. Immunohistochemically, the tumor was positive for cytokeratin and placental alkaline phosphatase but negative for hCG and human placental lactogen. The tumor was subsequently diagnosed as ETT.

CONCLUSION

It was difficult to make a definitive diagnosis of ETT using only a cytologic specimen. The diagnosis of ETT is facilitated by a combination of cytologic, histopathologic and clinical findings.

[Clinicopathologic analysis of uterine epithelioid trophoblastic tumor]

OBJECTIVE

To study the clinicopathologic features, immunophenotype, differential diagnosis and prognosis of uterine epithelioid trophoblastic tumor(ETT).

METHODS

From 2000 to 2007, 5 ETTs cases were diagnosed in the affiliated Women's Hospital, School of Medicine, Zhejiang University. The pathologic characteristics and immunophenotype of the tumors were analyzed by histological examination and immunohistochemistry of CK18, p63, inhibin-alpha, HCG, HPL, PLAP and Ki-67. The clinical prognostic factors were evaluated based on a following-up data with a period of 11 - 50 months.

RESULTS

The overall prevalence of ETT was 0.48% among all the gestational trophoblastic diseases patients received in the same period. Five ETT patients were in the reproductive ages with a median of 33 years. Histologically, the tumor showed an invasive, nodular growth consisting of uniform mononuclear trophoblastic cells. There were zones of hyaline material in the tumour nests. Necrosis was commonly seen with a characteristic geographic pattern. Immunohistochemically, all cases displayed a diffuse CK18 and p63 positivity, to be either positive focally or negative for HCG, HPL and PLAP staining. Inhibin-alpha staining was positive or negative either in the 5 cases. Two patients died of the tumour relapse: one died after 1 year with the tumor having a high mitotic activity (averagely 15 mitotic figures per 10 high-power fields), and the other died of lung metastasis 2 years after the diagnosis.

CONCLUSIONS

ETT is a rare trophoblastic disease with distinct clinicopathological features and immunostaining patterns. A high mitotic index and lung metastasis are indicators for an unfavorable prognosis.

Villotrophoblastic pulmonary nodule with implantation site intermediate trophoblasts after induced abortion

We describe a case of villotrophoblastic pulmonary nodule with a hitherto unrecognized implantation site intermediate trophoblasts (ISITs) in an asymptomatic 19-year-old woman, who had an induced abortion 1 month before the discovery of a pulmonary nodule. This 8-mm-sized nodule was incidentally identified on chest computed tomography during routine postoperative follow-up for osteosarcoma, for which she was treated with surgery and chemotherapy 3 years previously. The nodule was located in the subpleural lung parenchyma and was composed histologically of a few chorionic villi and trophoblasts surrounded by fibrinoid materials, with individually scattered intermediate trophoblasts at the periphery of the nodule. The intermediate trophoblasts were strongly immunopositive for cytokeratin, human placental lactogen, and Mel-CAM (CD146), but immunonegative for human chorionic gonadotropin and p63, characteristic features of ISITs. Our case indicates that villotrophoblastic pulmonary emboli have the potential to implant after migration from their original sites through the invasive property of ISITs.

Uterine epithelioid trophoblastic tumor in an African green monkey (Chlorocebus aethiops sabaeus)

A uterine mass was detected on physical exam in a multiparous African green monkey as an incidental finding, and the well-circumscribed mass was removed via hysterectomy. Histologically, the mass consisted of sheets, nests, and cords of uniform intermediate trophoblastic cells with eosinophilic or clear cytoplasm. These neoplastic cells aggregated around blood vessels, forming islands of viable tumor cells amid extensive areas of coagulative necrosis with calcification in a 'geographic' pattern of necrosis. Immunohistochemistry of the trophoblastic cells revealed strong and diffuse staining for pancytokeratin AE1/3 and p63, with weak and moderate staining for human placental lactogen and placental alkaline phosphatase, respectively. Immunohistochemical staining for smooth muscle actin, epithelial membrane antigen, and human chorionic gonadotropin was negative. Overall, the histologic and immunohistochemical features of this tumor were consistent with those of epithelioid trophoblastic tumor. This rare tumor type has not been reported previously to occur in African green monkeys.

[Clinicopathologic study of tumors of intermediate trophoblasts]

OBJECTIVE

To study the clinicopathologic features and immunophenotype of placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT).

METHODS

During the period from 1959 to 2005, a total of 1012 cases of gestational trophoblastic disease were diagnosed in Beijing Obstetrics and Gynecology Hospital. Six cases of PSTT and a case of ETT were retrieved from the archives of Beijing Obstetrics and Gynecology Hospital. Immunohistochemical study for cytokeratin 18, human chorionic gonadotropin (hCG), human placental lactogen (hPL), Mel-CAM (CD146), placental-like alkaline phosphatase (PLAP), epithelial membrane antigen (EMA), inhibin-alpha and proliferative cell nuclear antigen (PCNA) were performed. The morphologic features and immunohistochemical findings were compared with those of the controlled group which consisted of 20 cases of early gestational villi with decidua basalis and 20 cases of hydatidiform moles with implantation site.

RESULTS

The mean age of patients with PSTT was 32.4, while the age of patients with ETT was 36. Major clinical findings included irregular vaginal bleeding and amenorrhea. Preoperative serum hCG level varied from normal to moderately elevated. Serum testosterone level was raised in 1 case. Uterine curettage could achieve an accurate pathologic diagnosis in 60% of cases. ETT involved mainly the lower uterine segment and endocervix. Histologically, PSTT cells permeated between the myometrial fibers and vessels either individually or connecting in cords or sheets in a manner reminiscent of the implantation site reaction. ETT composed of a relatively uniform population of mononuclear trophoblastic cells, clumping together in nests as the cell islets associating with eosinophilic, fibrillary and hyaline material and necrotic debris, forming a "geographic map" like pattern. Immunohistochemical study for hPL, hCG, Mel-CAM (CD146) and PLAP was most helpful for the differential diagnosis. The duration of follow-up varied from 14 months to 19 years. One case of PSTT developed metastasis in pancreas, 5 months after the operation. The remaining patients survived without tumor recurrence.

CONCLUSIONS

PSTT is a tumor of implantation site intermediate trophoblasts while ETT differentiates towards chorionic-type intermediate trophoblasts. The different pathologic features and immunophenotype observed were closely related with the difference in tumor cell differentiation. An accurate pathologic diagnosis of the uterine curettage material is important for the clinical management. According to the limited follow-up data available, the clinical behavior of ETT is seemed similar to that of PSTT.

Das Urothelkarzinom mit trophoblastischer Differenzierung

Urothelium carcinomas with beta HCG positive markers are a rarity in tumour differentiation. Syncytiotrophoblastic and, in a few cases, cytotrophoblastic giant cells are typical for this carcinoma. Such differentiation has an intensified potential for invasiveness and is accompanied by increased angiogenesis. In the present case, the mixture of trophoblastic cells indicates a common stem cell. In comparison with beta HCG negative transitional cell carcinoma, the prognosis is bad for beta HCG positive carcinoma. For this reason, a radical operation should be taken into consideration as early as possible.

Uterine Epithelioid Trophoblastic Tumour in a Red-tailed Guenon (Cercopithecus ascanius)

Epithelioid trophoblastic tumour (ETT), a rare neoplasm of chorionic-type intermediate trophoblastic cells in the human female, was diagnosed in the uterus of a red-tailed guenon, a non-human primate. The animal, having had two live births, had a recent history of heavy vaginal bleeding. Four years after the last known pregnancy, the animal developed a large invasive mass involving the uterus, right ovary and abdominal wall. The tumour was removed surgically, but at necropsy 1.5 years later was found to have a recurrent neoplasm. Histologically, the original mass consisted of nests and cords of mononuclear intermediate trophoblastic cells whose borders were accentuated by intimately associated eosinophilic hyaline extracellular proteinaceous material. Extensive coalescing areas of necrosis with mineralization surrounding islands of viable neoplastic cells created a "geographical" pattern of necrosis. Immunohistochemical examination revealed that neoplastic cells were diffusely strongly positive for cytokeratin 18, and focally positive for human placental lactogen. The histopathological and immunolabelling patterns were consistent with ETT in human beings. This is the first reported case of epithelioid trophoblastic tumour in a non-human species.

[Study on the indication of surgical resection of pulmonary metastasis of malignant trophoblastic tumor]

OBJECTIVE

To investigate the indication of lung lobectomy in patients of malignant trophoblastic tumor with lung metastasis.

METHODS

Data on a total of 629 cases of malignant trophoblastic tumor of stage III-IV in Peking Union Medical College Hospital from 1990 to 2003 were reviewed. Ninety-five cases including those that underwent lung lobectomy and cases with normal level of serum human chorionic gonadotropin-beta subunit (beta-hCG, < 2 IU/L) and residual pulmonary nodules after chemotherapy were selected and studied.

RESULTS

Lung lobectomies were performed on six cases of invasive mole with lung metastasis and the pathological results were all necrotic nodules;another 35 cases of invasive mole with normal level of serum beta-hCG but residual pulmonary nodules after chemotherapy have been followed up for 6 months to 11 years and all were stable of diseases (SD). Lung lobectomies were performed on 29 cases of choriocarcinoma with lung metastasis. Among them, there were 17 cases whose pathological results were hemorrhage and necrotic tissue without trophoblastic cells (negative pathological results), while trophoblastic cells could still be detected in 12 cases of resected lung specimens (positive pathological results). Twenty-five cases of choriocarcinoma with normal serum beta-hCG but residual pulmonary nodules after chemotherapy were followed up, five cases had progress of disease (PD) and 20 were SD. There were no significant differences of age, stage and the last pregnancy between the positive and negative pathological results, SD and PD groups, respectively. However, the number of chemotherapeutic courses for decreasing beta-hCG from 10 IU/L to 2 IU/L and the total courses in the group of positive pathological results and PD group were significantly more than that of negative pathological results group and SD group (P = 0.01, P = 0.001).

CONCLUSIONS

For invasive mole, lung metastasis can be successfully treated by chemotherapy alone. Patients with residual pulmonary nodules but normal serum beta-hCG after chemotherapy can be followed up and spared lung lobectomy. For choriocarcinoma, slowly decreasing of beta-hCG from 10 IU/L to 2 IU/L is a high risk for chemoresistance, and it is an indication for thoracotomy. Progression of disease after multiple chemotherapy courses should be treated with lung lobectomy.

Postmenopausal bleeding resulting from placental site trophoblastic tumor of the uterus: a case report

BACKGROUND

Placental site trophoblastic tumor (PSTT) is the least common form of gestational trophoblastic disease. Occurrence of PSTT after menopause is extremely rare.

CASE

A 53-year-old woman complained of postmenopausal bleeding 6 years after cessation of her menstrual periods. On dilatation and curettage and on hysterectomy and bilateral salpingo-oophorectomy later, PSTT was found in the uterus with myometrial invasion and no metastasis. Serum human chorionic gonadotropin levels before and after the operation were 15 and < 1 IU/mL, respectively. Hysterectomy was performed.

CONCLUSION

Because of PSTT's rarity, limited information is known about its natural history, and there is no reliable means to predict clinical outcome. Thus, patients must be evaluated on a case-by-case basis.

Placental site trophoblastic tumor of the uterine cervix occurring from undetermined antecedent pregnancy

A cervical polyp complicated by severe hemorrhage was removed from a 43-year-old Japanese woman (gravida 0), who had undergone tubectomy on the right side 10 years previously. The polyp was diagnosed by immunohistochemical studies as placental site trophoblastic tumor of the cervix, but no metastatic foci were found in any other uterine site. The tumor was further demonstrated by PCR polymorphisms to possess two genomic DNA of the patient and her husband. Serum beta-hCG and urinary hCG titers were both low, which rapidly fell to 0.8 mIU/mL after a total hysterectomy and remained 0.2 mIU/mL after dismission. She has been uneventful for 3 years.

[Difficulties and biases of interpretation in cases of the trophoblast disease]

The trophoblastic disease (TD) is an unifying term for the nosologicunits: Mola hydatidosa, Mola hydatidosa invasivum, Chorionepithelioma. This kind of trophoblast pathology has geographic differences in the expression but the its overall incidence is not high. The clinicians often fail to consider the possibility of trophoblastic disease due to its low incidence rate. The forms of TD have clinical manifestations that are not specific. There are principles, which taken into account, could help the clinicians put the right diagnosis. Two cases of the clinical practice are reviewed in maintenance of this opinion.

[Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumour]

OBJECTIVE

To evaluate the role of lung lobectomy in the patients of tumor with lung metastases.

METHODS

A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985-2002 at PUMC hospital was retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma.

RESULTS

Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage IIIa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage IIIb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage IV had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission (63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission (88%). Tuberculosis was found in 2 patients.

CONCLUSIONS

Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.

Coexisting epithelioid trophoblastic tumor and choriocarcinoma of the uterus following a chemoresistant hydatidiform mole

The epithelioid trophoblastic tumor is an unusual type of trophoblastic tumor. Herein, we describe a patient with coexisting epithelioid trophoblastic tumor and choriocarcinoma in the uterus. The patient had a history of hydatidiform mole with recurrent elevation of human chorionic gonadotrophin level that is resistant to chemotherapy. Histopathologic and immunohistochemical examination showed distinctive differences between the 2 trophoblastic tumors. The development of epithelioid trophoblastic tumor may be related to the persistence of locally invasive disease, which was unresponsive to chemotherapy. The patient responded well to surgery. The presence of an epithelioid trophoblastic tumor should be considered in chemoresistant gestational trophoblast tumor.

Placental site trophoblastic tumor

Placental site trophoblastic tumor (PSTT) is an uncommon form of gestational trophoblastic disease (GTD) with variable spectrum of clinical behavior. PSTT can occur after a normal pregnancy, spontaneous abortion, termination of pregnancy, ectopic pregnancy or molar pregnancy. Surgery is the primary treatment. Chemotherapy has an established role in loco-regionally advanced and metastatic disease. Many studies indicate that mitotic index is an important prognostic indicator. This article reviews the literature on this rare disease.

Epithelioid trophoblastic tumor (ETT) initially interpreted as cervical cancer

The epithelioid trophoblastic tumor (ETT) is a rare form of trophoblastic disease and shows a wide spectrum of differential diagnoses and clinical behavior. A 53-year-old woman presented with ETT presumably originated in spontaneous delivery of 25 years ago and was initially diagnosed as cervical cancer on cervical punch biopsy followed by radical hysterectomy. The uterus showed a small tumor restricted to the cavum with no cervical infiltration, resembling ETT in histologic and immunohistochemical features. The difficulties and clues in distinguishing ETT from nontrophoblastic lesions are discussed.

[Hysterectomy after caesarean section]

OBJECTIVES

The indications for hysterectomy after caesarean section, postoperative period, and pathological examination of women. In whom hysterectomy hampered operated delivery, are being hereby analysed.

MATERIALS AND METHODS

The study group consisted of 15 patients who gave birth in I Clinic Medical Academy in Warsaw in 1995-2001.

RESULTS

In 7 with 15 women (46.7%) the supravaginal amputation was carried on at the rest in 8 (53.3%), the corpus and cervix of uterine was resected. In pathomorphological examination a trophoblast growth into uterine muscle was found. In 8 women (53.3%). In 5 (33.3%) in histological examination empty vessels were recognized. In one patient (6.7%) carcinoma praeinvasivum of uterine cervix and in one (6.7%) carcinoma of ovary were found.

CONCLUSIONS

Uterine atonia and abnormalities of placentae were the main indications for hysterectomy after delivery.

Epithelioid trophoblastic tumor of the endocervix: a case report

BACKGROUND

It is difficult to recognize epithelioid trophoblastic tumor (ETT) as a trophoblastic disease because of its rarity and growth pattern simulating a carcinoma.

CASE REPORT

A 36-year-old woman with stage IB(1) squamous cell carcinoma of the uterine cervix and a high serum beta-human chorionic gonadotropin (beta-hCG) level underwent radical hysterectomy with pelvic and para-aortic lymphadenectomy. However, light microscopic findings and immunohistochemical studies with pan-cytokeratin, epithelial membrane antigen, inhibin-alpha, beta-hCG, and human placental lactogen revealed ETT of the endocervix. The patient is alive with no evidence of disease 12 months after surgery.

CONCLUSION

Before the patient is resorted to radical surgical interventions for assumed cervical carcinoma, ETT should be ruled out in women of reproductive age with endocervical tumors and elevated serum beta-hCG levels.

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.

Detection of beta-subunit human chorionic gonadotropin mRNA in the peripheral blood of patients with nonmetastatic gestational trophoblastic disease

OBJECTIVE

The aim of this study was to detect beta-subunit human chorionic gonadotropin (beta(h)CG) mRNA in the peripheral blood samples of patients with nonmetastatic gestational trophoblastic disease (GTD) undergoing hysterectomy.

METHODS

Heparinized peripheral blood samples were obtained from four patients with nonmetastatic GTD before, during, and after hysterectomy. The beta(h)CG mRNA expression was examined by reverse transcriptase-polymerase chain reaction using beta(h)CG primers. The expression of beta(h)CG mRNA was quantified using a densitometer.

RESULTS

Beta(h)CG expression was detected in all patients before and during hysterectomy. The expression of beta(h)CG mRNA during operation was so high that it could not be quantified using densitometer. The expression decreased rapidly after operation.

CONCLUSIONS

Disseminated trophoblastic cells are present in the peripheral blood even in cases without metastasis. Trophoblastic cells circulating in the peripheral blood can be reduced by surgical intervention.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue.

METHODS

This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases.

RESULTS

Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05).

CONCLUSIONS

Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.

Choriocarcinoma and epithelial trophoblastic tumor: successful treatment of relapse with hysterectomy and high-dose chemotherapy with peripheral stem cell support: a case report

BACKGROUND

Post-termchoriocarcinoma is a rare complication of pregnancy. The presence of epithelioid trophoblastic elements may lead to the persistence of locally invasive disease which is unresponsive to multiagent chemotherapy. Relapse is associated with an estimated mortality rate of 30%.

CASE

We present a case of Stage IC post-term choriocarcinoma and epithelioid trophoblastic tumor. While the metastatic sites in the lungs responded to multiagent chemotherapy, a hysterectomy was required to treat persistent disease in the uterus. The patient relapsed within 4 months of completion of chemotherapy. Relapse was treated with high-dose chemotherapy with peripheral stem cell support. The patient is alive with no evidence of disease 23 months posttransplant.

CONCLUSIONS

The application of multimodality treatment and high-dose chemotherapy resulted in a successful outcome for this patient, indicating a potential role for high-dose therapy in patients who suffer a relapse of choriocarcinoma.

Treatment of gestational trophoblastic tumors

Gestational trophoblastic tumors (invasive mole, choriocarcinoma, and placental site trophoblastic tumor) should be classified according to the National Cancer Institute (NCI), World Health Organization (WHO), and International Federation of Gynecology and Obstetrics (FIGO) criteria into nonmetastatic, low-risk metastatic, and high-risk metastatic categories. Nonmetastatic tumors (FIGO Stage I) can be treated with a variety of single-agent methotrexate or actinomycin D protocols, resulting in cure of essentially all patients. Metastatic low-risk tumors (FIGO Stages II and III, WHO score < 8) should be treated with 5-day dosage schedules of methotrexate or actinomycin D, with cure rates approaching 100%. Metastatic high-risk tumors (FIGO Stage IV, WHO score > 7) require combination chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO) with or without adjuvant radiation therapy and surgery to achieve cure rates of 80% to 90%.

Is lack of response to single-agent chemotherapy in gestational trophoblastic disease associated with dose scheduling or chemotherapy resistance?

OBJECTIVE

The aim of this study was to determine whether in the management of low-risk gestational trophoblastic neoplasia (GTN) the administration of 5-day courses of 12 microg/kg actinomycin D is effective following the failure of 1.25 mg/m(2) "pulsed" actinomycin D.

METHODS

Patients with low-risk GTN who failed to respond to 1.25 mg/m(2) pulsed actinomycin were switched to the 5-day course of 12 microg/kg actinomycin.

RESULTS

Patients with low-risk GTN who failed to respond to pulsed actinomycin were changed to the same chemotherapy agent, actinomycin D, given as a 5-day course at 12 microg/kg. Four of the five responded and one required methotrexate to achieve remission.

CONCLUSIONS

Pulsed biweekly actinomycin and pulsed weekly methotrexate have been shown to have a higher failure rate than the 5-day regimens of the same medications. This study demonstrates that failure of pulsed actinomycin may be successfully treated by a 5-day course of the same medication. It appears that with the pulsed regimens cytotoxic exposure of trophoblastic cells to the medication is too brief and the 5-day course permits more cells to be in cycle. It is suggested that, following failure of a pulsed regimen, the patient is given the same chemotherapy as a 5-day course, rather than switching from actinomycin to methotrexate or vice versa. This conserves options for chemotherapy in GTN.

Human chorionic gonadotropin (hCG) beta-core fragment is produced by degradation of hCG or free hCG beta in gestational trophoblastic tumors: a possible marker for early detection of persistent postmolar gestational trophoblastic disease

The present study was undertaken to investigate whether human chorionic gonadotropin (hCG) beta-core fragment (hCG beta cf) was directly produced by gestational trophoblastic tumors. Immunoreactivity of hCG beta cf was demonstrated in the extracts as well as in the culture media of hydatidiform mole tissues. It was also present in the extracts of choriocarcinoma tissues, and its molar concentration exceeded that of intact hCG. The presence of hCG beta cf was then confirmed by gel chromatography and Western blot analysis. Immunohistochemistry showed localization of hCG beta cf immunoreactivity to the syncytiotrophoblasts and scattered cells in the stroma of mole tissue, and to syncytiotrophoblastic cells in choriocarcinoma. Immunoreactivity of hCG beta cf was also detected in the sera of the patients with gestational trophoblastic disease, although the hCG beta cf/hCG ratio was less than one hundredth of that in the tissue extracts. Serial measurement of serum hCG beta cf levels after mole evacuation showed that they declined much more rapidly than those of hCG and became undetectable in the patients with subsequent spontaneous resolution, while hCG beta cf remained or became detectable before the rise of hCG was observed in the patients with subsequent persistent trophoblastic disease. Taken together, these results suggest that hCG beta cf is directly produced by gestational trophoblastic tumors, and monitoring of hCG beta cf in the serum after mole evacuation may be useful for early prediction of subsequent development of postmolar persistent trophoblastic disease.

Adjuvant hysterectomy in low-risk gestational trophoblastic disease

OBJECTIVE

To evaluate the efficacy of adjuvant hysterectomy with chemotherapy for women with low-risk gestational trophoblastic disease.

METHODS

One hundred fifteen consecutive Japanese women (16-52 years old) with low-risk gestational trophoblastic disease (46 with metastatic disease and 69 without) were treated initially with single-agent chemotherapy (etoposide in 85, methotrexate in 27, and actinomycin D in three) with or without adjuvant hysterectomy, and 97 patients (84.3%) achieved primary remission with those treatments. Eight women (9.4%) treated with etoposide required other regimens because of drug resistance or toxicities. The total dose of etoposide given to achieve primary remission was analyzed in 77 women who received etoposide alone or with adjuvant hysterectomy.

RESULTS

In 34 women with metastatic disease, the mean (+/- standard deviation [SD]) total dose of etoposide was not significantly different with and without adjuvant hysterectomy (2857 +/- 842 mg versus 2815 +/- 815 mg; P =.957; Mann-Whitney U test). However, in 43 women without metastases, the total dose of etoposide was significantly less in those who had adjuvant hysterectomies than in those who did not (1750 +/- 635 mg versus 2545 +/- 938 mg; P <.05; Mann-Whitney U test).

CONCLUSION

Adjuvant hysterectomy decreased the total dose of etoposide given to achieve primary remission in women with nonmetastatic, low-risk gestational trophoblastic disease. If the lesions of gestational trophoblastic disease are confined to the uterus and the woman has no desire to preserve fertility, she should be informed of adjuvant hysterectomy as a treatment option.

Etoposide and cisplatin/etoposide, methotrexate, and actinomycin D (EMA) chemotherapy for patients with high-risk gestational trophoblastic tumors refractory to EMA/cyclophosphamide and vincristine chemotherapy and patients presenting with metastatic placental site trophoblastic tumors

PURPOSE

To evaluate the results of etoposide, cisplatin/etoposide, methotrexate, and actinomycin D (EP/EMA) chemotherapy in patients with gestational trophoblastic tumors (GTTs), who have relapsed after or who have become refractory to EMA/cyclophosphamide and vincristine (CO) chemotherapy, and in patients presenting with metastatic placental site trophoblastic tumors (PSTTs).

PATIENTS AND METHODS

We have treated a total of 34 patients with GTT and eight patients with metastatic PSTT with the EP/EMA chemotherapy schedule.

RESULTS

Twenty-two patients received EP/EMA because of apparent drug resistance to EMA/CO, and because the human chorionic gonadotropin (hCG) was near normal, they were not assessable for response. Twenty-one of these patients (95%) are alive and in remission. In the group where the hCG was high enough to confirm a response (greater than one log fall in hCG) to EP/EMA, all 12 patients responded and nine of these patients (75%) are alive and in remission. We have treated three patients with PSTT where the interval from antecedent pregnancy was less than 2 years, and all patients (100%) are alive and in remission. We have treated five patients where the interval from antecedent pregnancy was greater than 2 years and one fifth (20%) remain in remission. The survival for patients with GTT is 30 (88%) out of 34 patients and four (50%) out of eight patients for PSTT, giving an overall survival for these two cohorts of 34 (81%) out of 42 patients. The toxicity of this schedule is significant, with grade 3 or 4 toxicity (National Cancer Institute common toxicity criteria) recorded in hemoglobin (21%), WBC (68%), and platelets (40%). The role of surgery in this group of patients is important and contributed to sustained remission in five patients (23%) and possibly helped an additional seven patients (32%).

CONCLUSION

EP/EMA is an effective but moderately toxic regimen for patients with high-risk GTT who become refractory to or relapse from EMA/CO chemotherapy. Also, EP/EMA clearly has activity in patients with metastatic PSTT.

[The role of hysterectomy in the therapy of gestational trophoblastic tumor]

OBJECTIVE

To evaluate the role of hysterectomy for patients with gestational trophoblastic tumor.

METHODS

A total of 68 cases of gestational trophoblastic neoplasia treated by hysterectomy from 1985-1997 at PUMC hospital was retrospectively analyzed. Thirty-eight cases were diagnosed as choriocarcinoma and 30 as invasive mole.

RESULTS

Twenty-three elder patients who didn't desire to preserve fertility were selected for hysterectomy after short courses of chemotherapy. Twenty-two of them had complete remission (95.6%). The average total course of chemotherapy was 4.2. Of twenty-seven chemo-refractory cases who were suspected of an isolated lesion in the uterus, delayed hysterectomy as an adjunct to chemotherapy was performed. Twenty of them achieved complete remission (74.1%), with an average 9.4 courses of chemotherapy. Emergency hysterectomy was indicated in 18 patients with uterine perforation or life-threatening hemorrhage. Seventeen of the emergent cases had complete remission (94.4%), who had received an average 7.6 courses of chemotherapy.

CONCLUSION

Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, hysterectomy remains an important adjunct treatment in a selected subset of patients. Modified radical hysterectomy is recommended for the indicated patients.

[Role of surgical interventions in the treatment of patients with trophoblastic tumor resistant to chemotherapy]

A retrospective evaluation of 85 case histories of chemotherapy-resistant trophoblastic disease treated at the Center's clinic (1975-1996) was carried out. Both therapy efficacy and survival rates were lower in patients operated on prior to chemotherapy and during medication. However, excision of resistant foci of trophoblastic tumor contributed to the effectiveness of chemotherapy.

Identification of persistent trophoblastic diseases based on a human chorionic gonadotropin regression curve by means of a stepwise piecewise linear regression analysis after the evacuation of uneventful moles

Among the 191 patients with complete hydatidiform moles who were diagnosed and treated at Kyushu University Hospital from 1982 until 1996, 167 patients were diagnosed with uneventful moles retrospectively. The serial beta human chorionic gonadotropin (hCG) values in the 167 patients with uneventful moles were analyzed by a stepwise piecewise linear regression analysis in order to establish a normal regression curve of a human chorionic gonadotropin after a molar pregnancy. This normal regression curve is considered to be excellent regarding sensitivity (24/24-100%) and to be equivalent to the identification based on a plateau or a rise regarding specificity (156/167-93.4%). To distinguish patients with persistent trophoblastic disease (PTD) from uneventful moles, this normal curve is thus considered to be accurate since the accuracy was 180/191 (94. 2%). The weeks exceeding the normal regression curve in 24 PTD patients were 5.04 +/- 3.85 weeks and were also earlier than the weeks based on a plateau or a rise (P = 0.01). Within 7 weeks after evacuation, in 21/24 (87.5%) of the PTD cases, the beta-hCG values exceeded the normal range, while in only 14/24 (58.3%) the beta-hCG showed a change in the shape of a plateau or a rise. In addition, in 19/24 (79.2%) of the PTD patients, the time exceeding the normal range was shorter than the time exhibiting a plateau or a rise in the beta-hCG change. The above findings thus led us to conclude that this normal regression curve was useful for discriminating PTD from uneventful moles more precisely and more quickly than by identification based on a plateau or a rise.

Changing face of gestational trophoblastic tumor

During the years there have been many advances in the diagnosis and treatment of gestational trophoblastic tumor (GTT) with marked improvement in the outcome. At the same time in Korea there have been many social and economic changes which also have had a marked influence on the outcome. The purpose of this study was to review the changes that have occured among patients admitted to Il Sin Christian Hospital, Pusan, Korea over the past four decades.

Management of high-risk gestational trophoblastic disease

Multimodality therapy with combination chemotherapy employing etoposide, high-dose methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO), and adjuvant radiotherapy and surgery, when indicated, has resulted in cure rates of 80-90% in patients with high-risk metastatic gestational trophoblastic tumors. However, approximately 25-30% of high-risk patients will have an incomplete response to first-time chemotherapy or will relapse from remission. Most of these patients will have a clinicopathologic diagnosis of choriocarcinoma, metastases to sites other than the lung and vagina, more than eight metastases and/or failed inappropriate previous chemotherapy, resulting in very high World Health Organization scores. Salvage chemotherapy with cisplatin/etoposide, usually in conjunction with bleomycin or ifosfamide, as well as surgical resection of sites of resistant disease in selected patients, will result in a cure in most patients. New technology, such as the use of colony-stimulating factors to prevent treatment delays and dose reductions or high-dose chemotherapy with or without autologous bone marrow transplantation or peripheral blood stem cell support, may play an important role in the future management of patients who develop drug resistance.

[Evaluation of emergency surgery in gestational trophoblastic tumours]

We retrospectively analyzed 27 cases of gestational trophoblastic neoplasia treated by emergency surgery from 1985-1996 at PUMC hospital. Seventeen cases were diagnosed of choriocarcinoma and 10 were invasive mole. Sixteen out of 27 patients were subjected to hysterectomy because of uterine perforation or severe uterine bleeding; 4 cases received unilateral oophorectomy because of torsion of theca lutein cyst. Emergency open surgery and excision of the metastatic brain tumour were undertaken in 3 patients with elevated intracranial pressure caused by brain edema and haemorrhage; 2 patients showed lifethreatening haemorrhage from vaginal metastatic tumour and were managed by operative intervention. Partial jejunectomy was performed in 2 patients due to rupture of jejunal metastatic mass. Of these 27 cases, 17 hadn't been treated with chemical reagents and 6 cases had received one course of chemotherapy before surgical procedures. After multiple courses of combined chemotherapy postoperatively, 23 patients had achieved complete remission. It is concluded that surgical intervention plays an important role in patients with trophoblastic disease when emergency situations (e.g. life-threatening haemorrhages) occur; early diagnosis and prompt initiation of chemotherapy might have rendered surgery unnecessary.

Placental site nodule occurring in a fallopian tube

The placental site nodule (PSN), a recently described benign lesion of intermediate trophoblast, is usually an incidental finding in younger women. It is a well-circumscribed, round to oval lesion that is extensively hyalinized and immunohistochemically stains for cytokeratin, placental alkaline phosphatase (PLAP), human placental lactogen (HPL) and, focally, for human chorionic gonadotropin (HCG) and epithelial membrane antigen (EMA). Thus far, the cases reported have been found in endometrial curettage or hysterectomy specimens. The pathogenesis of PSN is yet to be ascertained; however, there is wide acceptance of the fact that it represents a remnant of the placental implantation site. If this is indeed the case, it should not be surprising to find PSN occurring at sites of ectopic gestation. We describe herewith a case in which PSN was found in a fallopian tube segment resected in a postpartum tubal ligation.

Magnetic resonance imaging in patients with gestational trophoblastic disease

RATIONALE AND OBJECTIVES

The authors describe the magnetic resonance (MR) imaging characteristics in patients with gestational trophoblastic disease (GTD) before and after therapy and to correlate these findings with human gonadotropin levels and the specific histology of GTD.

METHODS

Thirteen women (mean age, 30.1 years) with elevated human chorionic gonadotropin (HCG) levels and histologically proven GTD underwent MR examinations of the pelvis. Magnetic resonance imaging was performed on a 1.5-tesla unit. Axial and sagittal proton density-weighted and T2-weighted and sagittal T1-weighted sequences were obtained. Four patients underwent follow-up studies after 4 and 8 weeks to monitor the response to therapy. Gestational trophoblastic disease was histologically proven with curettage in 11 patients and with hysterectomy in two cases.

RESULTS

Nine patients had a diffusely enlarged uterus with pathologic signal intensities. In four patients, a focal tumor mass was observed. All patients showed loss of the zonal anatomy of the uterus in at least one local area. In 11 patients, no uterus zones could be identified throughout the entire uterus. Pathologic dilated tumor vessels were evident in all patients. In all four cases in which follow-up imaging studies were obtained, uterus size, signal intensities, identification of uterus zones, and uterus vessels returned to normal.

CONCLUSION

Magnetic resonance imaging shows trophoblastic tumor infiltration as diffuse uterus enlargement, focal tumor masses, loss of zonal anatomy of the uterus, and pathologic uterine vasculature; this seems to be the most reliable MR imaging finding in patients with GTD. No correlation was found between MR imaging changes and HCG levels or specific histologic types of GTD.

[Diagnosis and treatment of extrauterine pregnancy in The Netherlands]

OBJECTIVE

To inventory current policy in the diagnosis and treatment of ectopic pregnancy (EP) in the Netherlands.

DESIGN

Questionnaire.

SETTING

Academic Medical Centre, Amsterdam, the Netherlands.

METHODS

A questionnaire was sent to all I30 departments of gynaecology in the Netherlands.

RESULTS

The response rate was 94% (n = 122). Transvaginal ultrasonography was very widely used, whereas results of serum hCG measurements were only available within 24 h in 75% of the departments. Eighty-three per cent of the respondents screen for EP in high-risk patients. Laparoscopic surgery was used in 62% of the departments, open surgery in 9%, whereas in 28% the surgical technique depended upon the skills of the operating gynaecologist. If desire for pregnancy was present, 53% of the departments operated always conservatively, 2% always radically, whereas in 43% conservative surgery was performed only in case of a healthy ipsilateral tube. Methotrexate was used in 38% of the departments for persistent trophoblast, in 16% as primary treatment of interstitial pregnancies and in 13% as primary treatment for tubal pregnancy.

CONCLUSION

Diagnostic strategies for EP in the Netherlands are homogeneous and in conformity with the state of the art in the literature. For treatment, laparoscopic techniques are widely used. In almost all departments, conservative surgery is the treatment of choice. Use of methotrexate is so far limited to treatment of persistent trophoblast after a failure of conservative surgery.

Treatment of low-risk metastatic gestational trophoblastic tumors with single-agent chemotherapy

OBJECTIVE

Our purpose was to evaluate the efficacy and toxicity of single-agent chemotherapy and to identify risk factors associated with chemotherapy resistance in the treatment of low-risk metastatic gestational trophoblastic tumors.

STUDY DESIGN

We reviewed the records of all patients with gestational trophoblastic tumors treated with single-agent chemotherapy at the John I. Brewer Trophoblastic Disease Center of Northwestern University between 1962 and 1992. A total of 92 patients with low-risk metastatic gestational trophoblastic tumors by National Cancer Institute criteria were identified. Patients received methotrexate (n = 61), actinomycin D (n = 4), alternating methotrexate and actinomycin D (n = 5), or hysterectomy with methotrexate (n = 20) or actinomycin D (n = 2).

RESULTS

All 92 patients with low-risk metastatic gestational trophoblastic tumors were cured. Primary remission was achieved with initial single-agent therapy in 62 patients (67.4%). A second sequential single agent was used because of drug resistance in 20 patients (21.7%) or drug toxicity in 10 patients (10.9%). Only one patient (1%) needed multiagent chemotherapy to be cured. Adjuvant hysterectomy was performed in 22 patients (23.9%). Surgery was not required to remove resistant tumor foci. Chemotherapy toxicity, most commonly stomatitis, occurred in 36 patients (39.1%), but none of these effects was life threatening. Large vaginal metastasis was the only identifiable factor significantly associated with failure of initial single-agent chemotherapy (p = 0.03).

CONCLUSION

In this large series of patients with low-risk metastatic gestational trophoblastic tumors, sequential single-agent chemotherapy with methotrexate and actinomycin D provided safe and extremely effective treatment.

[Treatment of patients with trophoblastic tumors in the Academic Medical Center: 31 patients in 10 years, 1983-1992]

OBJECTIVE

Evaluation of the treatment of patients with gestational trophoblastic disease.

SETTING

Academic Medical Centre, Amsterdam.

DESIGN

Descriptive.

METHOD

Clinical data from all patients treated between 1983 and 1992 were collected.

RESULTS

Thirty-one patients were treated in this period. Eighteen patients had persistent trophoblast after a molar pregnancy, 7 had choriocarcinoma after a normal pregnancy and in 6 patients the obstetrical history was unclear. The initial treatment strategy was chosen on the basis of prognostic factors; low-risk patients received mono-chemotherapy (Methotrexate) and high-risk patients were treated with polychemotherapy (EMA/CO). In 15 cases adjuvant therapy was necessary. Complete remission was achieved in 29 patients, 2 patients died. The adverse effects of the chemotherapy were generally mild.

CONCLUSION

Persistent trophoblastic disease has an unpredictable presentation and course. Therefore treatment should preferably be given in a reference centre.