Ectopic gestational trophoblastic disease: a case series review.

OBJECTIVE: To highlight the clinical presentation, treatment, histological review and outcome of patients referred to the Sheffield Centre with possible ectopic gestational trophoblastic disease (GTD). STUDY DESIGN: A retrospective case note review of patients with possible ectopic GTD referred to the Sheffield Centre between 1997 and 2010 was performed. RESULTS: During the 13 years of this retrospective study 6,708 patients were registered at the Centre with GTD, of whom 42 had possible ectopic GTD. Most patients presented with abdominal pain and/or vaginal bleeding (67%). Ectopic pregnancy was diagnosed by ultrasound scan in 19%. Laparoscopic removal of ectopic pregnancy was carried out in 50% of cases; the rest underwent laparotomy for removal of ectopic conceptus. Histological review of slides was performed in 19 cases for whom there was clinical concern. This resulted in 12 confirmed cases of ectopic GTD: 4 choriocarcinomas, 5 partial moles and 3 complete moles. No evidence of metastasis was recorded in any of the cases. Three patients diagnosed with ectopic choriocarcinoma needed chemotherapy. Two responded to methotrexate and 1 needed second-line chemotherapy. All patients are alive and free of disease. CONCLUSION: Ectopic GTD is rare and still overdiagnosed. Presentation is the same as for conventional ectopic pregnancy. Central review of the histology should be undertaken, especially in cases where there is clinical, hCG level or histopathologic concern. Conventional chemotherapy for gestational trophoblastic neoplasia is effective. Prognosis remains excellent.

Postpartum choriocarcinoma presentation, management and survival.

OBJECTIVE: To determine the clinical presentation and outcome of postpartum choriocarcinoma. STUDY DESIGN: Case note review of patients with choriocarcinoma treated at the Sheffield Trophoblastic Disease Centre. RESULTS: Thirty-five patients were identified between 1977 and 2005. Mean age was 27 years (range, 21-37). Thirty-three patients complained of persistent postpartum hemorrhage, and in 3 cases there were other symptoms. Two patients presented with nongynecologic symptoms. Mean time until diagnosis was 7 weeks postpartum (range, 0-60), with a mean delay from onset of symptoms to treatment of 7 weeks (maximum, 19). Twenty patients had metastatic disease, but this did not correlate with delay in diagnosis. The mean International Federation of Gynecology and Obstetrics score was 10. Multidrug regimens were used in most patients; however, 8 low-risk patients had a complete response with methotrexate alone. The mean survival was 7.8 years (range, 1-21). Two patients died from disease. CONCLUSION: Postpartum choriocarcinoma presents mainly with vaginal bleeding, and there is often a delay in diagnosis despite being under the care of gynecologists. In the small numbers that present with nongynecologic symptoms there is a rapid awareness of the possibility of gestational trophoblastic neoplasia; nevertheless, the outcome may be fatal, especially in the presence of symptomatic brain metastases.

Placental site trophoblastic tumour: clinical features and management.

OBJECTIVE: To describe the clinical features, treatment and outcome of all consecutive patients with placental site trophoblastic tumour (PSTT) treated at the Sheffield Trophoblast Centre and to compare these findings to other reports. METHOD: All cases of PSTT on the Sheffield Trophoblastic Tumour Centre database from 1984 to 2004 were reviewed. Data obtained included age at diagnosis, antecedent pregnancy (AP), interval from antecedent pregnancy until diagnosis, presenting features, presenting serum human chorionic gonadotrophin hormone (hCG) level, number and sites of metastases, treatment received, outcome and follow-up. RESULTS: Seventeen patients with PSTT were identified from the database which incorporates a total of 7489 cases of trophoblastic disease. Fourteen (70.6%) were more than 30 years old at presentation; 5 were over 40. The median interval from pregnancy to diagnosis was 18 months (range 6 months to 22 years). The outcome of antecedent pregnancy was a female in 11 out of the 13 patients where the sex was known. Eleven (70.6%) of patients presented with irregular vaginal bleeding, with or without a preceding period of amenorrhoea. All 8 patients with non-metastatic (Stage I) disease were alive and well after hysterectomy (6), chemotherapy alone (1) or hysterectomy and chemotherapy (1) whereas only 4 of 9 patients with metastatic (Stage III/IV) disease were alive and well after treatment with chemotherapy and hysterectomy. CONCLUSION: PSTT is rare and accounts for 0.23% cases of gestational trophoblastic disease referred to this centre. It has a variety of presenting features and its course is unpredictable. Metastatic involvement and antecedent pregnancy interval greater than 4 years are poor prognostic factors. Hysterectomy is the primary mode of treatment in the majority of cases. However, chemotherapy can still play a major role when curative surgery is not feasible.