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PubMed2006

Epithelioid trophoblastic tumor: review of a rare neoplasm of the chorionic-type intermediate trophoblast.

We present a brief review of epithelioid trophoblastic tumor, a rare trophoblastic neoplasm derived from chorionic-type intermediate trophoblastic cells that typically presents in reproductive-age women between 1 and 18 years following a previous gestation. Histologic features include a nodular growth pattern of monomorphic, epithelioid cells within a hyaline matrix. Areas of necrosis and mitotic activity (0-9 mitoses per 10 high-power fields) are additional features of this neoplasm. Positive immunostaining for p63 and cytokeratin, frequent location in the lower uterine segment and endocervix, as well as the epithelioid appearance can lead to confusion with squamous cell carcinoma. Inhibin-alpha is typically expressed, as well as focal, more variable expression of other trophoblastic markers including beta-human chorionic gonadotropin, human placental lactogen, placental alkaline phosphate, and Mel-CAM (CD148). The clinical behavior of this rare form of gestational trophoblastic disease is difficult to predict. Although most cases follow a benign course following resection, there is a potential for metastatic disease.

Adult↗

PubMed2004

Placental site trophoblastic tumor: an overview.

OBJECTIVE: To analyze 15 consecutive cases of placental site trophoblastic tumor seen in a single reference institution for gestational trophoblastic disease, San Gerardo Hospital, Monza, Italy. STUDY DESIGN: Consecutive patients affected by placental site trophoblastic tumors were selected from our computerized database. RESULTS: There were 15 patients with placental site trophoblastic tumor, with a median age of 35 years. The antecedent pregnancy was a term one in 6 cases (40%), a miscarriage in 4 cases (27%), a termination in 2 cases (13%) and a molar abortion in 2 cases (13%). In 1 case the previous pregnancy was unrecognized. The median interval from the last pregnancy was 12 months, and the presenting symptom in 11 cases was vaginal bleeding, in 2 cases amenorrhea, in 1case a nephrotic syndrome and in 1 case, presenting with metastatic disease, hemoptysis. Six patients were treated using neoadjuvant chemotherapy with etoposide/methotrexate/actinomycin-etoposide/ vincristine (EMA-CO) followed in 5 of 6 (83%) cases by hysterectomy. One patient had only medical treatment with EMA-CO because of a strong desire for or childbearing and had a complete response; after 15 months she was free from disease. The last 9 patients underwent surgery as the first therapy. Among these patients 1 had presented with metastatic pulmonary disease and underwent chemotherapy, with complete disappearance of the pulmonary lesions. Two of these 9 patients had a relapse; the mirst patient had a pelvic and bladder relapse, and 14 months after multiple chemotherapy and surgery, she died. The second had a suburethral relapse 2 months after initial surgery; after chemotherapy and surgery she was well and free of disease. CONCLUSION: Our experience suggests that the role of chemotherapy may be reconsidered not only for metastatic disease but als of or uterine disease when choosing conservative management in young, fertile patients who desire childbearing. Chemotherapy may play an important role in avoiding relapse or early metastases even in patients who underwent hysterectomy as primary treatment.

Adult↗

PubMed2004

Epithelioid trophoblastic tumor of the broad ligament: a case report and review of the literature.

We report an epithelioid trophoblastic tumor, a recently delineated type of gestational trophoblastic tumor (GTT), discovered in the right broad ligament of a 41-year-old woman. The patient had gestational trophoblastic disease and was treated with methotrexate regimen 15 times 10 years earlier. The yellowish, spongy tumor with tiny hemorrhage spots was located in the right broad ligament, adherent to the right ovary. Microscopically, the tumor was circumscribed, with a pushing border, and the epithelial-differentiated tumor cells grew in cords, nests, and sheets within which were aggregates of hyaline material and necrotic debris. Most tumor cells were mononuclear with distinct cell borders, eosinophilic cytoplasm, and had nuclei with occasional indistinct nucleoli. Scattered multinucleated cells consistent with syncytiotrophoblastic cells were also present. Immunohistochemical staining revealed strong diffuse reactivity for cytokeratins (AE1/AE3, CAM 5.2, CK18), and focal reactivity, mainly in syncytiotrophoblastic cells, for beta-human chorionic gonadotropin, human placental lactogen, and inhibin-alpha. The histologic and immunohistochemical features were characteristic of epithelioid trophoblastic tumor and helped to distinguish the tumor from other trophoblastic tumors and squamous cell carcinoma. Our unusual findings in this case included a high level of serum beta-human chorionic gonadotropin, an unusual tumor location, and a higher Ki-67 proliferative index of 47.2%.

Adult↗

PubMed1989

Free alpha subunit of human chorionic gonadotropin in women with non-trophoblastic tumors.

Patterns of secretion of free alpha subunit in 242 women with non-trophoblastic tumors were studied. In 4 patients molecular forms of alpha subunit were investigated. In normal menstruating women, day to day fluctuations of alpha subunit (36 to 4871 ng/day) with a peak at midcycle were commonly observed. This makes measurement of the alpha subunit as a tumor marker difficult to interpret in this group of women. On the other hand, the secretion of alpha subunit in postmenopausal women was relatively stable (from 50 to 450 ng/day). Thus the incidence of elevated alpha subunit secretion (greater than 400 ng/day) in postmenopausal patients with non-trophoblastic tumors was as follows; cervical cancer (29.9%), ovarian cancer (50%), corpus cancer (37.5%), vulvar cancer (33.3%), lung cancer (53.3%), gastrointestinal tract cancer (80%). The elevation of the alpha subunit was unrelated to the histological type of cancer. Discordant secretion of hCG and its subunits were noted. The incidence of elevated hCG secretion (greater than 100 ng/day) for the same group of postmenopausal patients with non-trophoblastic tumors was 44.8% for cervical cancer, 100% for ovarian cancer, 62.5% for corpus cancer, 33.3% for vulvar cancer, 26.7% for lung cancer and 40% for gastrointestinal tract cancer. The incidence of isolated alpha subunit secretion in cervical cancer stages III and IV, lung cancer and gastrointestinal tract cancer (40-43%) was higher than that in other cancers (0-27%). For cervical cancer, the more advanced disease was associated with higher alpha subunit levels. The molecular forms of alpha subunit in 4 patients with non-trophoblastic tumors were studied by gel HPLC.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗

PubMed2003

Gestational trophoblastic tumor after medical abortion.

BACKGROUND: Nonmetastatic gestational trophoblastic tumor occurring after early elective medical abortion using mifepristone and misoprostol is unusual. CASE: A young woman at 6 to 7 weeks' gestation presented with brown spotting requesting medical abortion. Pretreatment ultrasound was consistent with an abnormal pregnancy. Passage of tissue ensued after mifepristone-misoprostol administration. Recovery was normal, with a postabortion ultrasound on day 16 showing a reduction in intracavitary contents. The patient declined surveillance with serial beta-human chorionic gonadotropin (beta-hCG) levels and was lost to follow-up. Sixty days after initial treatment, she presented to a hospital with a history of intermittent bleeding and underwent curettage, revealing a complete hydatidiform mole. Chemotherapy was instituted when levels of hCG plateaued. Complete hCG regression occurred after three weekly injections of methotrexate, and postmolar surveillance is uneventful to date. CONCLUSION: Gestational trophoblastic tumor may occur after early medical abortion.

Abortifacient Agents, Steroidal↗

PubMed1994

The utilization of Doppler ultrasonography with color flow mapping in the diagnosis and evaluation of malignant trophoblastic tumors.

The Doppler ultrasound with color flow mapping image has been recently applied for the evaluation of gynecologic diseases, in particular, malignant trophoblastic tumors with the characteristic abundant blood flow. Doppler color flow mapping of uterine artery and intratumoral blood vessels was performed at a regular interval in all 26 patients including 3 cases of lost for follow up. Systolic/diastolic (S/D) ratio representing blood flow was measured in 19 cases of malignant trophoblastic tumors and 7 cases of hydatidiform mole diagnosed at the department of Obstetrics and Gynecology, Yonsei University, College of Medicine. The initial mean S/D ratio and standard deviation(SD) of uterine artery in 11 remitted and 5 non-remitted patients were 2.72 +/- 1.31 and 2.69 +/- 1.80, respectively. No significant difference was noted between two groups. However, the final S/D ratio of uterine artery in remitted group showed significantly higher values than non-remitted group, of which values were 6.23 +/- 2.38 and 3.08 +/- 1.54, respectively (P < 0.05). In aspect of blood flow changes in malignant trophoblastic tumors after chemotherapy, remitted group showed entirely disappeared blood flow, while non-remitted group had persistent blood flow. The mean S/D ratio and SD measured in hydatidiform mole patients were 5.43 +/- 1.65, of which value reflects higher resistance than malignant trophoblastic tumors. Also blood flow was not detected in all cases. This study suggests that color flow mapping Doppler ultrasound can be a useful method in diagnosing and monitoring the treatment in malignant trophoblastic tumors along with the conventional serum beta-hCG titration.

Adult↗

PubMed1994

Vascular patterns of gestational trophoblastic tumors by color Doppler ultrasound.

BACKGROUND: Destruction of uterine vasculature is a common phenomenon in gestational trophoblastic tumors. The authors categorized such uterine vasculature by color Doppler ultrasound and studied its clinical significance. METHODS: Color Doppler ultrasound was performed in 28 patients with gestational trophoblastic tumors. The vascular morphologic manifestations were recorded, and the peak systolic velocity and resistance index of uterine artery were calculated. Serum beta-human chorionic gonadotropin (hCG) levels were measured periodically to monitor chemotherapy response. Seventeen uneventful postmole uteri were used as controls. Two-tailed Student's t-test and Fisher's exact test were used for statistical analysis. RESULTS: The gestational trophoblastic tumors were categorized as diffuse type (N = 7), lacunar type (N = 16), and compact type (n = 5) according to their vascular patterns. The mean serum beta-hCG level at diagnosis in diffuse type lesions (6608 +/- 6320 mIU/mL) was significantly lower than in the lacunar type (40462 +/- 39735 mIU/mL; P = 0.04) and compact type (212114 +/- 205126 mIU/mL; P = 0.02), whereas the level in compact type lesions was significantly higher than in the lacunar type (P = 0.003). Lacunar type lesions exhibited a significantly lower uterine artery resistance index (0.51 +/- 0.13) than diffuse type (0.66 +/- 0.10; P = 0.03) or compact type lesions (0.70 +/- 0.06; P = 0.02). All lesions exhibited significantly higher peak systolic velocity than control subjects (P < 0.001); however, no significant difference was observed among them. Brief courses (< 5 cycles) of chemotherapy cured more diffuse type (6 of 7) than lacunar type (3 of 15, P = 0.006) or compact type lesions (0 of 5, P = 0.008). Histopathologic diagnosis was available for 11 lesions. They were invasive mole in seven lacunar type lesions and choriocarcinoma in four compact type lesions. CONCLUSION: Vascular morphologic patterns of gestational trophoblastic tumors by color Doppler ultrasound correlated well with beta-hCG levels, uterine hemodynamics, chemotherapy response, and possibly the histopathologic diagnosis.

Arteries↗

PubMed2001

Metastatic placental site trophoblastic tumor: a case report.

Placental site trophoblastic tumor (PSTT) is very rare. It is an unusual variant of gestational trophoblastic neoplasia usually confined to the uterus, although 10% of patients have metastases. The clinical behaviour of PSTT varies and despite knowledge of its histology, diagnosis of this rare form of trophoblastic disease and prediction of its biological behaviour remains difficult due to only a few cases reported in literature.

Adult↗

PubMed1996

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.

Adolescent↗

PubMed2000

Prolonged remission of recurrent, metastatic placental site trophoblastic tumor after chemotherapy.

BACKGROUND: Placental site trophoblastic tumor (PSTT) is a form of gestational trophoblastic neoplasm that is frequently resistant to chemotherapy. In most cases disease is confined to the uterus and can be cured by curettage or simple hysterectomy. Patients with metastases, however, frequently have progression of disease and die despite aggressive multiagent chemotherapy. CASE: A 31-year-old woman was found on review of uterine curettings to have a PSTT. Imaging studies revealed multiple lung lesions, a liver lesion, and an enlarged irregular uterus. Hysterectomy and staging surgery revealed a large tumor in the endometrial cavity and multiple metastases. She was treated with etoposide-methotrexate-dactinomycin and cyclophosphamide-vincristine and had a complete clinical remission. Six months later, however, she had a recurrence. She was then treated with six cycles of etoposide-methotrexate-dactinomycin and etoposide-cisplatin. Three years after completion of the second regimen she is without evidence of disease. CONCLUSION: Treatment with multiagent chemotherapy can produce long-term remission, even in patients with recurrent, metastatic PSTT. Addition of platinum may be helpful in patients who have recurred or progressed after treatment with non-platinum-containing regimens.

Adult↗

PubMed2002

Management of brain metastases in patients with high-risk gestational trophoblastic tumors.

OBJECTIVE: To analyze the results of current treatment of patients with brain metastases from high-risk gestational trophoblastic tumors. STUDY DESIGN: Consecutive patients treated between June 1981 and the end of 2000 with brain metastases from high-risk gestational trophoblastic tumors were selected from our computerized database. RESULTS: There were 39 patients with cerebral metastases from high-risk gestational trophoblastic tumors, and 30 (79.5%) of these patients are alive and in remission. Four patients died within 8 days of admission from disease extent. If these four patients are excluded, the survival of the remaining 35 patients is 86%. Eight patients had received prior chemotherapy, and 3 died of the disease. The antecedent pregnancy (AP) was term delivery in 23 (59%), and in 2 of those patients there was a prior history of a molar pregnancy in an AP. Six patients had a history of molar pregnancy as the AP, and in 10 the type of AP was uncertain. The presence of both liver and brain metastases was a particularly adverse prognostic combination, and only one of five patients is still alive in remission. No deaths or relapses occurred beyond 30+ months from the initiation of high-dose etoposide, methotrexate and actinomycin D with cyclophosphamide and vincristine chemotherapy. CONCLUSION: With appropriate management, the outlook for patients with brain metastases from high-risk gestational trophoblastic tumors is good, and the majority of patients achieved sustained remission and probably a cure with chemotherapy as the dominant form of treatment. When the tumor is sufficiently chemosensitive, the blood-brain barrier does not prevent disease elimination.

Adult↗

PubMed2004

Placental site trophoblastic tumor in a postmenopausal female--a case report.

BACKGROUND: Placental site trophoblastic tumor (PSTT) is tumor of intermediate trophoblast, seen commonly in reproductive age group. CASE: A 63-year-old postmenopausal woman presented with vaginal discharge, occasional bleeding and a large uterine mass suspicious of malignancy. The uterus ruptured during hysterectomy. A large, necrotic and hemorrhagic tumor was seen in the endometrial cavity infiltrating through the myometrium into serosa. The tumor cells were large pleomorphic, polygonal with variable mitosis. The histological differential diagnosis included choriocarcinoma, epithelioid trophoblastic tumor, epithelioid leiomyosarcoma and poorly differentiated carcinoma. The tumor cells were positive for cytokeratin and beta-hCG and negative for smooth muscle antigen and HMB-45. The final histological diagnosis was PSTT. CONCLUSION: PSTT is rare in postmenopausal females. It is difficult to diagnose clinically as well as histologically.

Female↗

PubMed2006

Placental site trophoblastic tumor (PSTT) with metastases to lungs and adrenal glands.

Placental site trophoblastic tumor (PSTT) is a rare type of gestational trophoblastic disease and three quarters of cases follow a normal pregnancy. Metastases are very rare but when present are often widespread. It has 10 to 20% mortality rate when not treated properly. We present report of a case of placental site trophoblastic tumor with metastases to left adrenal gland and both lungs.

Adrenal Gland Neoplasms↗

PubMed1999

Outcome of pregnancies occurring before completion of human chorionic gonadotropin follow-up in patients with persistent gestational trophoblastic tumor.

OBJECTIVE: To determine the outcome of pregnancies occurring before completion of human chorionic gonadotropin follow-up in patients treated with chemotherapy for gestational trophoblastic tumor. METHODS: Retrospective record review of patients with gestational trophoblastic tumor who conceived before standard hCG follow-up was completed during 1973-1998. RESULTS: Forty-three patients treated for gestational trophoblastic tumors conceived before human chorionic gonadotropin follow-up was completed. The antecedent pregnancy was complete mole in 31 (72.1%) and partial mole in 12 (27. 9%) patients. Of the 43 patients, 39 (90.7%) had stage I, 1 had stage II, and 3 had stage III disease. The mean interval from human chorionic gonadotropin remission to new pregnancy was 6.3 months (range 1-11 months). Ten patients underwent elective termination and four patients were lost to follow-up. Of the remaining 29 patients, 22 (75.9%) had term live births, 3 (10.3%) had preterm delivery, 3 had spontaneous abortion, and 1 (3.5%) had a repeat mole. Two cases of fetal anomalies were detected; one was inherited polydactyly and the other was hydronephrosis. One patient developed choriocarcinoma with lung involvement and underwent cesarean section at 28 weeks; a normal fetus was delivered and no choriocarcinoma was detected in the placenta. CONCLUSION: Pregnancies occurring in patients treated for gestational trophoblastic tumor before standard human chorionic gonadotropin follow-up is completed may continue under close clinical surveillance since the majority have a favorable outcome. However, patients should also be advised of the low but important risk of delayed diagnosis in case tumor relapse develops during early subsequent pregnancy.

Adult↗

PubMedDate not supplied

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.

Adult↗

PubMed2002

Subsequent pregnancy experience in patients with molar pregnancy and gestational trophoblastic tumor.

Modern therapy for molar pregnancy and gestational trophoblastic tumors has resulted in high cure rates and preservation of fertility, even in the setting of metastatic disease requiring chemotherapy. Patients and their partners facing future pregnancy after treatment for gestational trophoblastic disease express fear related to risk of disease recurrence and outcome of subsequent pregnancies. Data from the New England Trophoblastic Disease Center on later pregnancies following complete and partial mole as well as persistent gestational trophoblastic tumor show that patients, in general, can anticipate normal subsequent pregnancy outcomes.

Female↗

PubMed2000

[Clinical study of four cases with malignant gestation trophoblastic tumor after mifepristone abortion].

OBJECTIVE: To describe the clinical characteristics of malignant gestational trophoblastic tumor after medical abortion used by mifepristone combined with misoprostol and its diagnosis and differential diagnosis from incomplete abortion. METHODS: Four cases with malignant gestational trophoblast tumor after medical abortion were presented focusing on the clinical manifestation and the methods of diagnosis and differential diagnosis. RESULTS: Irregular vaginal bleeding and abnormal high level of beta-human chorionic gonadotropin (hCG) in plasma were the common manifestation of the gestational trophoblast tumour and incomplete abortion after medical abortion. However, beta-hCG of the former after curettage was still higher by dynamic monitoring. Malignant gestational trophoblast tumor showed rich blood flow signal and low blood flow resistance index (RI, RI < 0.5) in uterus in color doppler echography, digital subtraction angiography (DSA) with abnormal enlargement of the arteria of uterine, arteriovenous fistula beside the uterine were the main characteristics of malignant gestational trophoblast tumour. CONCLUSIONS: Pay attention to the early stage malignant gestational trophoblast tumour among patients with abnormal vaginal bleeding after medical abortion. beta-hCG and DSA were the most effective methods to diagnose and differentially diagnose choriocarcinoma from the incomplete abortion among the patients with abnormal vaginal bleeding after medical abortion.

Abortifacient Agents, Steroidal↗

PubMed1999

Pregnancy with primary tubal placental site trophoblastic tumor--A case report and literature review.

Placental site trophoblastic tumor (PSTT) is a rare trophoblastic neoplasm with malignant potential. The diagnosis and prognosis of this rare disease remain difficult. A case of tubal PSTT with the primary manifestation of internal bleeding at 30 weeks' gestation is presented. Emergency exploratory laparotomy and right partial salpingectomy were performed initially. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were done immediately after cesarean section at 34 weeks' gestation. No further adjuvant therapy was given after surgery. No evidence of tumor recurrence or signs of metastasis were noted during 12 months of follow-up. Heterotopic pregnancy, one with intrauterine normal pregnancy and the other with implanting in the right fallopian tube and placental site trophoblastic tumor transformation, was proposed. To our knowledge, this is the first such case in the English literature.

Adult↗