Placental site trophoblastic tumor (PSTT): a case report and review of the literature.

Placental site trophoblastic tumor (PSTT), also known as atypical choriocarcinoma, syncytioma, chorioepitheliosis or trophoblastic pseudotumor, is a rare gestational trophoblastic disease (0.25-5% of all trophoblastic tumors) and it is composed by neoplastic proliferation of intermediate trophoblasts at placental implantation site. It consists of aggregates or sheets of large, polyhedral to round, predominantly mononucleated cells with a characteristic vascular and myometrial invasion. Main differential diagnoses are gestational choriocarcinoma (GC) and epitelioid trophoblastic tumor (ETT). We present a case of PSTT in a 25-year-old woman. Neoplastic cells showed moderate/high nuclear pleomorphism, abundant amphophilic, eosinophilic and clear cytoplasm, numerous mitotic figures (10 mitoses/10 HPF), and myometrial invasion. Other features are necrosis, vascular invasion with replacement of myometrial vessels by tumor cells and hemorrhage. The patient showed typical low serum ß-hCG levels and high serum humane placental lactogen (hPL) levels.

The role of the ultrasound examination in atypical placental site trophoblastic tumour differential diagnosis and management. A case report.

Placental site trophoblastic tumour (PSTT) is a very rare and unique form of gestational trophoblastic tumour, representing about 1-2% of all gestational trophoblastic tumours. Usually, the pattern is a slow growing nodule implicating the endometrium and myometrium, accompanied by abnormal uterine bleeding. Three ultrasound types of PSTT are described, but thereis no specific characteristic for diagnosis. We present the case of a patient with an atypical placental site trophoblastic tumour diagnosed two months after a caesarean scar pregnancy. In the presented case there are several particularities, such as the rapid growth and progression of the tumour, the limitation to the myometrium and the difficulty of the differential diagnosis and approach.

Placental site trophoblastic tumour: five challenges of patient clinical management.

Placental site trophoblastic tumour is a rare form of gestational trophoblastic disease accounting for about 1%-2% of all trophoblastic tumours. Diagnosis and management of placental site trophoblastic tumour can be difficult.We report a case of a 30-year-old woman diagnosed with a placental site trophoblastic tumour and identify the challenges in diagnosis and treatment of this rare situation. The presenting sign was abnormal vaginal bleeding that started 3 months after delivery. Image exams revealed an enlarged uterus with a heterogeneous mass, with vesicular pattern, and the increased vascularisation serum human chorionic gonadotropin level was above normal range. The histological diagnosis was achieved through hysteroscopic biopsy. Staging exams revealed pulmonary micronodules. The patient was successfully treated with hysterectomy and chemotherapy. The latest follow-up (37 months after diagnosis) was uneventful, and the patient exhibited no signs of recurrence or metastasis.

Epithelioid trophoblastic tumor in a postmenopausal woman: A case report and review of the literature in the postmenopausal group.

Epithelioid trophoblastic tumor is a rare gestational trophoblastic neoplasm arising from the intermediate trophoblasts. Although usually seen in the reproductive period, it may be encountered during the postmenopausal period. A 56-year-old woman who had given her last birth 21 years ago presented to the hospital with a complaint of postmenopausal bleeding. She had a history of eight live pregnancies and had been in menopause for 4 years. With the help of typical histopathologic and immunohistochemical findings, a diagnosis of "epithelioid trophoblastic tumor" was made. The diagnosis was made at an advanced age and the case had extraordinary features such as high mitotic activity and Ki-67 proliferation index (70%). Gestational trophoblastic neoplasms are rare causes of postmenopausal bleeding which may cause differential diagnosis problem. They should be kept in mind even if the patient age does not comply with because of the differences in treatment.

Placental site trophoblastic disease.

A case study of a 38-year-old woman with a diagnosis of placental site trophoblastic tumor is presented. The patient had a 22-month history of amenorrhea since her last pregnancy, and a dilation and curettage procedure was performed after a 3.1×2.4×2.8 cm endometrial echogenic lesion was visualized on a pelvic ultrasound. When the diagnosis of placental site trophoblastic tumor was made by histopathologic and immunohistochemical analysis, complementary examinations including including pelvic magnetic resonance imaging (MRI) and a chest computed tomography (CT) were done. There was no evidence of disease outside the uterus, and a laparoscopic hysterectomy with bilateral salpingectomy was performed. After a surveillance period of 12 months, no disease recurrence was identified. Best imaging studies, treatment options, and proper surveillance for these type of tumors are discussed alongside the case study.

Placental site trophoblastic tumor and epithelioid trophoblastic tumor: Clinical and pathological features, prognostic variables and treatment strategy.

Placental site trophoblastic tumor [PSTT] and epithelioid trophoblastic tumor [ETT] are the rarest gestational trophoblastic neoplasias, developing from intermediate trophoblast of the implantation site and chorion leave, respectively. PSTT and ETT share some clinical-pathological features, such as slow growth rates, early stage at presentation, relatively low ßhCG levels and poor response to chemotherapy. The mortality rate ranges from 6.5% to 27% for PSTT and from 10% to 24.2% for ETT. Advanced stage, long interval between antecedent pregnancy and diagnosis, and presence of clear cells are the independent prognostic variables for PSTT, and they may be similar for ETT. Hysterectomy can represent the only therapy for early disease, whereas adjuvant chemotherapy should be reserved to patients with poor risk factors, such as an interval from the antecedent pregnancy >4 years, deep myometrial invasion or serosal involvement. Few cases of fertility-sparing treatment in young women have been reported. An individualized multidisciplinary approach, including chemotherapy and debulking surgery with abdominal and/or extra-abdominal procedures, is warranted for advanced disease. EP/EMA and TP/TE are the preferred regimens in this setting. Immunohistochemistry has sometimes shown expression of EGFR, VEGF, MAPK, PDGF-R and PD-L1, and therefore investigational studies on biological agents targeting these molecules are strongly warranted for chemotherapy resistant-disease.

Management of placental site trophoblastic tumor: Two case reports.

RATIONALE: Placental site trophoblastic tumor (PSTT) is a very rare malignant tumor, belonging to a family of pregnancy-related illnesses, called gestational trophoblastic diseases (GTD). Less than 300 cases of PSTT have been reported in literature, with an incidence of ≈ 1/50,000-100,000 pregnancies representing only 0.23% to 3.00% of all GTDs. PATIENT CONCERNS: Our report describes 2 additional cases of PSTT outlining their main diagnostic features and the subsequent management. The first case presented contemporary to a persistent hydatidiform mole in a 37-year-old woman, para 2042; whereas the second one originated 5 years after a miscarriage in 43-year-old woman, para 1031 with a previous diagnosis of breast cancer, and shared some features with placental site nodule (PSN), a benign condition. DIAGNOSIS: The first case had a difficult diagnosis because there was an amenorrhea of 11th week with high serum beta-human chorionic gonadotropin (beta-HCG) and an initial ultrasound image of vesicular mole. After the Dilatation and Curettage, histology confirmed the previous hypothesis. However, the final histology of PSTT was obtained after major surgery. On the contrary, the diagnosis of the second case was less challenging but surprising, thanks to a routine trans-vaginal ultrasound showing a suspicious endometrial thickness positive for PSTT at a subsequent hysteroscopic guided biopsy. INTERVENTIONS: The treatment consisted of hysterectomy and subsequent follow up. Lymphadenectomy or lymph node sampling were not performed due to the initial stage of the disease. OUTCOMES: In the first case, there were high values of serum beta-HCG that plummeted after the surgery, whereas in the second one they had been always negative. Hereafter, both went through a follow up with periodic serum oncological markers, imaging studies and clinical evaluation, which have showed negative result for 3 years and 15 months, respectively. LESSONS: A detailed gynecological ultrasound examination could be extremely helpful to understand the next diagnostic step of echo-guided D&C or hysteroscopic biopsy and for a pre-operative staging assessment. On the contrary, determining the serum beta-HCG's curve is crucial just in case of an initial positive value to pursue clinical evaluation and follow-up. In case of good prognostic factors, the main therapy remains hysterectomy.

Placental site trophoblastic tumor in early stage: a case report.

Here, the authors present a case of a placental site trophoblastic tumor (PSTT) in a 28-year-old gravida 1 para 1 living 1 woman three months after vaginal delivery of a female infant at diagnosis in 2014. The patient was FIGO Stage I and finally underwent a total laparoscopic hysterectomy with ovarian conservation. Subsequently, the patient received two cycles of EMA/CO chemotherapy. Patient is on regular follow-up (clinical exam, ß-hCG tests, pelvic and abdominal sonography) and has shown no signs of local or systemic recurrence for 24 months.

A well-circumscribed border with peripheral Doppler signal in sonographic image distinguishes epithelioid trophoblastic tumor from other gestational trophoblastic neoplasms.

As epithelioid trophoblastic tumor (ETT) shares similar clinical features with other gestational trophoblastic neoplasms (GTNs), it is likely to be clinically misdiagnosed and subsequently treated in an improper way. This study aimed to identify the sonographic features of ETT that are distinct from other GTNs, including placental site trophoblastic tumor (PSTT) and invasive mole/choriocarcinoma (IM/CC). Here, we retrospectively analyzed ultrasound images of 12 patients with ETT in comparison with those of 21 patients with PSTT and 24 patients with IM/CC. The results showed that maximal diameter and hemodynamic parameters were not significantly different among ETT, PSTT and IM/CC (P>0.05). However, a well-circumscribed border with hypoechogenic halo was identified in the gray-scale sonogram in all 12 cases of ETT, while only in 1 out of 21 cases of PSTT and 1 out of 16 cases of IM/CC (P<0.001 for ETT vs. PSTT or IM/CC). Moreover, a peripheral pattern of Doppler signals was observed in 11 out of 12 ETT lesions, showing relatively more Doppler signal spots around the tumor border than within the boundary, while a non-peripheral pattern of Doppler signals in all 21 PSTT cases and 14 out of 16 IM/CC cases: with minimal, moderate or remarkable signal spots within the tumor, but not along the tumor (P<0.001 for ETT vs. PSTT or IM/CC). These distinct sonographic features of ETT correlated with histopathologic observations, such as expansive growth pattern and vascular morphology. Thus, we draw the conclusions that the well-circumscribed border with peripheral Doppler signal may serve as a reliable sonographic feature to discriminate ETT from other types of GTNs. With further validation in a larger patient set in our ongoing multi-center study, this finding will be potentially developed into a non-invasive pre-operative GTN subtyping method for ETT.

Sonographic characteristics of placental site trophoblastic tumor.

OBJECTIVE: To investigate clinical features and ultrasound findings in cases of placental site trophoblastic tumor (PSTT). METHODS: Fourteen cases of PSTT treated at our institution between May 2004 and October 2010 were identified and the clinical features and findings on transvaginal sonography (TVS) were investigated. Pathological confirmation of PSTT was obtained in all cases. RESULTS: The most frequent symptoms associated with PSTT were abnormal vaginal bleeding, which was present in 11 cases, and amenorrhea, which was present in five cases. The interval from antecedent pregnancy to diagnosis was 4-36 (median, 12.5) months. Blood serum was positive for beta-human chorionic gonadotropin (ß-hCG) at the time of ultrasound examination, although the level was generally low, with a median of 166.2 IU/L (range, 4.5-3480.2). Sonographic presentation of PSTT was classified into one of three types according to the characteristics observed on TVS: Type I, heterogeneous solid mass in the uterine cavity (four cases), with minimal to a moderate degree of vascularization on color Doppler imaging; Type II, heterogeneous solid mass in the myometrium (six cases), with minimal to a high degree of vascularization (only one case was highly vascularized); and Type III, cystic lesions in the myometrium (four cases) with a high degree of vascularization (lacunar-type lesions). CONCLUSIONS: Combined with clinical features, characteristics demonstrated by TVS provide evidence for the suspicion of PSTT and could contribute to clinical decision making.

Chorangiocarcinoma of the placenta: a case report and clinical review.

OBJECTIVE: We describe a case of chorangiocarcinoma, a complex lesion consisting of a trophoblastic proliferation within a chorangioma, presenting in a term placenta. MATERIALS AND METHODS: The lesion was diagnosed by ultrasound at a second trimester check-up after amniocentesis, performed because of increased combined risk at first trimester screening for trisomy 21. After uncomplicated vaginal delivery, a healthy child was born and the placenta was expelled spontaneously. RESULTS: Gross examination of the placenta showed a well-demarcated mass, bulging paracentrally from the fetal surface. Histology revealed a trophoblastic proliferation inside a chorangioma, consisting of multiple nodules with characters of focal multinucleation and pleomorphic cell nuclei, extensive central necrosis and high mitotic activity. Immunohistochemical staining showed strong intensity for hCG; Ki-67 (MIB-1) demonstrated a high proliferation index. Histopathological and immunohistochemical profile was compatible with a malignant trophoblastic proliferation. CONCLUSIONS: This is only the fifth reported case of so-called "chorangiocarcinoma" of the placenta (Table 1). However, histopathologically only one reported case was identical to ours. A proliferation of atypical trophoblast was observed inside a chorangioma, which formed as it were a shield around the trophoblast. No extravascular stromal invasion was present. Follow-up revealed no metastases, either in the mother or the child, up to 3 months after birth.

Placental site trophoblastic tumor presenting as a friable cervical mass.

PURPOSE OF INVESTIGATION: Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic neoplasia (GTN) and primarily composed of intermediate trophoblasts. In contrast to other forms of GTN, PSTT presents with only mildly elevated levels of beta-hCG and immunohistochemical staining of tissue samples is a helpful tool for diagnosis. CASE AND RESULTS: A 38-year-old gravida 3, parity 3 female presented to the emergency department after three weeks of abnormal vaginal bleeding. The uterus was mildly enlarged, midline, and mobile with minimal discomfort. A necrotic, friable mass was protruding through the cervical os and biopsies were obtained. The serum beta-hCG was 13 mIU/ml. Computed tomography revealed a mass within the endometrial cavity and cervix but no significant lymphatic adenopathy or metastasis. Immunohistochemical staining was positive for cytokeratin AE1/AE3, E-cadherin, human placental lactogen (hPL), and alpha inhibin. Surgery was considered curative. CONCLUSION: PSTT presenting as a friable cervical mass is uncommon. Biopsies of this mass lead to the correct diagnosis. Several immunohistochemical stains are suggested in the literature to evaluate for PSTT. Clinically, it is prudent for physicians to differentiate PSTT from other forms of GTN because of the poor response of PSTT to chemotherapy.

Exaggerated placental site mimicking placental site trophoblastic tumor: case report and literature review.

Exaggerated placental site is defined as a non-neoplastic trophoblastic lesion featuring exuberant infiltration into the endometrium and myometrium by intermediate trophoblasts and syncytiotrophoblasts. Exaggerated placental site can occur following normal or ectopic pregnancy, abortion, or hydatidiform mole. We encountered a case of reactive exaggerated placental site seven months following normal pregnancy that clinically mimicked placental site trophoblastic tumor. Few reports have described the clinical course, histopathology and differential diagnosis of exaggerated placental site; we present our patient's case together with histopathological observations and review of related literature.

Exaggerated placental site reaction following an elective abortion.

We encountered a case of exaggerated placental site (EPS) reaction following an elective abortion. EPS is a miscellaneous trophoblastic lesion. There have been few reports describing its clinical course, and the ultrasonogram and magnetic resonance imaging characteristics have not been reported previously. We present the ultrasonogram and magnetic resonance imaging findings of EPS together with histopathological observations.

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

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

Ultrasound of the placenta: a systematic approach. Part I: Imaging.

Diagnostic ultrasound has been in use in clinical obstetrics for close to half-a-century. However, in the literature, examination of the placenta appears to be treated with less attention than the fetus or the pregnant uterus. This is somewhat unexpected, given the obvious major functions this organ performs during the entire pregnancy. Examination of the placenta plays a foremost role in the assessment of normal and abnormal pregnancies. A methodical sonographic evaluation of the placenta should include: location, visual estimation of the size (and, if appearing abnormal, measurement of thickness and/or volume), implantation, morphology, anatomy, as well as a search for anomalies, such as additional lobes and tumors. Additional assessment for multiple gestations consists of examining the intervening membranes (if present). The current review considers the various placental characteristics, as they can be evaluated by ultrasound, and the clinical significance of abnormalities of these features. Numerous and varied pathologies of the placenta can be detected by routine ultrasound. It is incumbent on the clinician performing obstetrical ultrasound to examine the placenta in details and in a methodical fashion because of the far reaching clinical significance and potentially avoidable severe consequences of many of these abnormalities.

Exclusion of lung metastases in placental site trophoblastic tumor using [18F]fluorodeoxyglucose positron emission tomography: a case report.

BACKGROUND: We present the first case using [18F]fluorodeoxyglucose positron emission tomography (PET) for the evaluation of multiple lung nodules in a woman with placental site trophoblastic tumor (PSTT) and history of pulmonary tuberculosis. CASE: PSTT was diagnosed by endometrial biopsy in a 38-year-old female, 11 months after an abortion. She had received medical treatment for pulmonary tuberculosis 8 years ago. Nodular lung lesions in upper and lower lung fields were noted on the chest X-ray and computed tomography, which was not shown on PET. She then received hysterectomy and complete remission of serum beta-hCG titer with stationary lung lesions in follow-up images were noticed thereafter. CONCLUSION: PET, as adjuvant study to conventional images, may help in the differentiation of chest lesions in PSTT.

Radiographic and hysteroscopic findings of a placental site nodule.

OBJECTIVE: To report a case of placental site nodule discovered on hysterosalpingogram and evaluated by sonohysterography and hysteroscopy in a patient presenting with infertility. DESIGN: Case report. SETTING: Academic reproductive endocrinology center. PATIENT(S): A 30-year-old gravida 1 para 1 receiving evaluation for secondary infertility. INTERVENTION(S): Hysterosalpingogram, sonohysterography, and operative hysteroscopy with excision. MAIN OUTCOME MEASURE(S): Diagnosis and treatment of intrauterine lesion. RESULT(S): Pathology of the excisional biopsy from operative hysteroscopy revealed a placental site nodule. CONCLUSION(S): We report one of the first radiographic and hysteroscopic findings of a placental site nodule. This case demonstrates that in addition to the most common causes of uterine filling defects seen on hysterosalpingogram and sonohysterography, rarer lesions like placental site nodule also need to be considered in the differential diagnosis. Placental site nodule is a benign lesion that requires correct diagnosis to distinguish it from other more serious placental findings, but long-term follow-up is unnecessary. Therapy consists of diagnosis and expectant management.