A 29 years old female, Para 2 presented with irregular vaginal bleeding started 4 months after an uncomplicated vaginal delivery of a term male infant. Her first delivery was also normal without any antenatal or postnatal complication. Otherwise her history was unremarkable. In referring hospital she was diagnosed as a case of retained product of conception on ultrasound. Serum beta human chorionic gonadotrophin (β-hCG) level was 4253 mIU/ml. Dilatation and curettage (D&C) done. Final pathology showed PSTT.
She was referred on January 28, 2013 for assessment and management to our Oncology centre at King Abdullah Medical City, Makkah, Saudi Arabia. On examination, a thin lean lady was markedly pale with tachycardia. Abdominal examination showed 14 week palpable uterus. Local examination showed mild bleeding, healthy external genitalia, and healthy cervix/vagina. At that time β-HCG was 14,889 mIU/ml. Her Hemoglobin (Hb) was 7.3 and she received four units of packed red blood cells (RBCs). Review of slides showed a neoplasm composed of proliferation of polyhedral mononuclear intermediate trophoblasts with extensive deposition of fibrinoid material confirming the diagnosis of PSTT.
Metastatic workup with CT scan of chest, abdomen, and pelvis done on February 2, 2013 showed innumerable pulmonary nodules scattered in both lungs, largest 8.4 mm in right middle lobe. Seven centimeter (cm) heterogenous mass filled the endometrial canal and extending to the level of cervix. The parametria were slightly hazy but no definite involvement was found with prominent both adenexa. No evidence of ascites nor lymphadenopathy (pelvic, abdominal, inguinal). All other structures were within normal limits.
Patient offered surgery (total abdominal hysterectomy) followed by chemotherapy but she refused treatment and left the hospital against medical advice. Four weeks later, she presented to emergency department with heavy vaginal bleeding. Hemoglobin was 6.6 mg/dl and received four units of packed RBCs. Abdominal examination showed 22 week sized uterus. A newly developed anterior vaginal wall mass of 4 × 4 cm was found. CT scan repeated CAP showed interval worsening of pulmonary nodules and enlarged uterus with anterior vaginal mass.
Patient agreed for surgery, underwent total abdominal hysterectomy and excision of anterior vaginal mass on March 3, 2013. Intra operatively uterus was found to be enlarged (20 weeks sized) with multiple areas of impending tumor perforation. Both tubes and ovaries were normal with no ascities or any intra-abdominal bleeding. Post-operative course was unremarkable. Repeated β-hCG (48 h post-op) was 6016 mIU/ml. The microscopic examination of uterus showed mixed trophoblastic tumor composed of chroriocarcinma (CC) and PSTT. Invasion of myometrium, and lymph-vascular invasion were identified. The CC component showed typical dimorphic picture consisting of syncytiotrophoblasts and cytotrophoblasts. Immunohistochemical staining for β-hCG revealed positive staining in this component. The PSTT which constitute about 20 % of tumor showed sheets of monomorphic intermediate trophoblasts and fibrinoid material. These cells were strongly positive for human placental lactogen (hPL), and inhibin, and negative for β-hCG, and P-63. Ki-67 proliferation index was high in CC component. (Figs. 1, 2).
Three weeks post surgery, combination chemotherapy EMA/CO protocol was started and continued 3 cycle after achieving normal β-hCG (quantitative β-hCG <4 mIU/ml). CT scan of the chest showed complete resolution of pulmonary metastasis. Currently she is in remission and under monthly follow up.