Conservative surgery in stage I placental site trophoblastic tumor: a report of 10 cases and literature review

doi:10.19401/j.cnki.1007-3639.2023.09.006

Abstract

Abstract:

Background and purpose: Placental site trophoblastic tumor (PSTT) is a rare type of malignant tumor. Because of its unique mode of invasion in the uterus and its insensitivity to chemotherapy, total hysterectomy is the primary recommendation. The purpose of this study was to investigate the feasibility and safety of conservative surgical treatment in patients with stage Ⅰ PSTT. Methods: The patients with stage Ⅰ PSTT admitted to Obstetrics and Gynecology Hospital of Fudan University from January 2015 to December 2021 were included, and those published on Pubmed and China National Knowledge Infrastructure (CNKI) from January 1990 to December 2021 were searched with the keywords of “placental site trophoblastic tumor” and “case”, “placental trophoblastic tumor” and “case” respectively. The clinicopathological data of the patients were collected and retrospectively analyzed. Results: A total of 10 cases admitted to Obstetrics and Gynecology Hospital of Fudan University were enrolled. The median age was 27 years. The most common symptom was irregular vaginal bleeding (70.0%). The median time of interval since antecedent pregnancy (ISAP) was 14.5 months. The median level of β-human chorionic gonadotrophin (β-hCG) was 124.51 mU/mL, and the diameter of the focus was 0.8-8.0 cm. All 10 patients admitted to Obstetrics and Gynecology Hospital of Fudan University achieved complete remission after initial treatment. The average follow-up time was 48.1 months and there was no recurrence. Three patients became pregnant naturally after treatment, including 2 cases of full-term pregnancy and delivery and 1 case of induced abortion because of unplanned pregnancy. Literature review of PSTT cases showed similar clinicopathological distribution and disease outcome. Conclusion: Conservative surgery could be an alternative choice for selected patients with stage Ⅰ PSTT, but more research is needed to provide evidence.

Key words: Placental site trophoblastic tumor, Conservative surgery, Prognosis

CLC Number:

R737.33

CHEN Jinjuan, WANG Xingran, LI Wenzhi, CHENG Yu, SUN Yihua, TAO Xiang, MA Fenghua, SUN Li, ZHAO Hongbo, LU Xin. Conservative surgery in stage I placental site trophoblastic tumor: a report of 10 cases and literature review[J]. China Oncology, 2023, 33(9): 857-865.

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Case	Age	Gravidity	Parity	Antecedent pregnancy	ISAP/month	Chief Complaint	β-hCG/(mU·mL^-1)
1	27	1	1	Term	12	Irregular vaginal bleeding	88.89
2	24	2	1	Term	12	Irregular vaginal bleeding	1 120.00
3	28	2	1	Term	14	Irregular vaginal bleeding	42.31
4	29	3	1	Hydatidiform mole	15	Elevated hCG	160.13
5	28	1	1	Term	28	Irregular vaginal bleeding	0.19
6	27	2	0	Abortion	30	Elevated hCG	363.90
7	28	2	0	Abortion	15	Irregular vaginal bleeding	2 281.00
8	27	1	1	Term	6	Elevated hCG	8.76
9	24	3	0	Abortion	17	Irregular vaginal bleeding	61.66
10	25	3	2	Term	8	Irregular vaginal bleeding	25.60

Case	Lesion size before surgery/cm	Lesion site	Lesion echo	Lesion border	Blood flow
1	8.0×5.5×6.9	Uterine cavity and posterior wall	Locally anechoic	Almost involving the uterine serous layer	++
2	5.6×5.0	Uterine cavity	Hypoechoic	Unclear border with the myometrium	+++
3	2.6×1.8×2.5	Uterine cavity	Iso- and hyper- echoic	Unclear border with the myometrium	+
4	4.1×4.2×3.4	Anterior wall	Hypoechoic	Almost involving the uterine serous layer	+++
5	0.8×0.8×0.7	Anterior wall	Iso- and hypoechoic	Close to the uterine cavity	±
6	3.9×3.3×3.2	Anterior wall	Iso echoic	3 mm to the uterine serous layer	++
7	4.9×4.6×4.8	Anterior wall	Non-uniform	Protruding into the uterine cavity	+++
8	NA	NA	NA	NA	NA
9	1.1×1.0×0.9	Uterine cavity	Iso echoic	Unclear border with the myometrium	+
10	2.4×1.5×2.4	Uterine cavity	Non-uniform	Unclear border with the myometrium	++

Case	Pathologic high-risk factors	Ki-67 proliferation index/%	Vascular remodeling
1	Necrosis and high mitosis	30	Yes
2	No	20	NA
3	No	NA	NA
4	Necrosis and high mitosis	30	Yes
5	No	5	No
6	High mitosis	20	Yes
7	High mitosis	20	Yes
8	No	30	NA
9	High mitosis	5	Yes
10	necrosis	20	NA

Case	Surgery			Chemo-therapy	Follow up/month	Pregnancy after treatment
Case	Diagnostic surgery	Therapeutic surgery	Surgery during follow up	Chemo-therapy	Follow up/month	Pregnancy after treatment
1	LULR^ab	No	No	EMA-EP*3	79-NED	0-fear of recurrence
2	LULR and left ovarian cystectomy^bc	No	No	EMA-EP*2	87-NED	1-full term delivery
3	LULR^b	No	Curettage^b	EMA-EP*2	87-NED	1-full term delivery
4	LULR and left ovarian cystectomy^a	No	Curettage and intrauterine adhesion separation^b	EMA-EP*3	45-NED	0-fear of recurrence
5	LULR^b	LULR^a	Curettage and intrauterine adhesion separation^b	No	44-NED	0-fear of recurrence
6	D&C	LULR^c	Intrauterine adhesion separation and IUD implantation^b	EMA-EP*4	46-NED	0-preparing for pregnancy
7	D&C	LULR^a	No	EP1^d, EMA-EP(6^d+2)	23-NED	0-hypomenorrhea
8	LULR^b	No	Curettage^b	No	32-NED	0-hypomenorrhea
9	D&C	LULR and IUD implantation^a	Removal of IUD, separation of cervical adhesion	No	26-NED	0-fear of recurrence
10	LULR^b	No	Curettage and intrauterine adhesion separation^b	No	12-NED	1-abortion

Characteristic	Case n(%)	Range	x±s/median, Q1-Q3	Characteristic	Case n(%)	Range	x±s/median, Q1-Q3
Chief complaint	34			Necrosis and hemorrhage	19
Irregular vaginal bleeding	18 (52.9)			Yes	7 (36.8)
Menopause	5 (14.7)			No	12 (63.2)
Irregular vaginal bleeding and menopause	3 (8.8)			Mitosis index/10HPF	22
Others	8 (23.5)			≤5	17 (77.3)
Gravidity	26			>5	5 (22.7)
1	12 (46.2)			Ki-67 proliferation index	22
2	5 (19.2)			≤10%	16 (72.7)
3	6 (23.1)			10%-≤30%	4 (18.2)
≥4	3 (11.5)			>30%	2 (9.1)
Parity	26			Surgery	40
0	8 (28.6)			Curettage	16 (40.0)
1	16 (61.5)			Local uterine lesion resection	20 (50.0)
2	2 (7.7)			Unknown	4 (10.0)
Antecedent pregnancy	37			Chemotherapy	40
Term	19 (51.4)			Before surgery	1 (2.5)
Abortion	13 (35.1)			After surgery	15 (37.5)
Hydatidiform mole	5 (13.5)			Both before and after surgery	7 (17.5)
ISAP/month	36	0-29	6, 2-11	Without chemotherapy	17 (42.5)
<12	28 (77.8)			Initial response	40
12-24	6 (16.7)			Remission	36 (90.0)
≥24	2 (5.6)			Persistence	4 (10.0)
Serum β-hCG/(mU·mL^-1)	29	2-5 775	120.3, 53.0-689.5	Follow up/month	40	2-144	36.3, 14.5-49.0
<10²	13 (44.8)			Outcome of follow up	40
10²-10³	10 (34.5)			No evidence of disease	40 (100.0)
10³-10⁴	5 (17.2)			Relapse	0 (0.0)
≥10⁴	1 (3.4)			Pregnant outcome	9
Tumor size/cm	10	0-3.6	2.1±1.3	Term	6
<3	7 (70.0)			Abortion	2
≥3	3 (30.0)			Pregnant	1
Invasion depth	12
Superficial	8 (66.7)
Deep	4 (33.3)