Placental site trophoblastic tumor: A review of 7 cases and their implications for prognosis and treatment

OBJECTIVE: To review cases of placental site trophoblastic tumor (PSTT) for prognostic factors and treatment implications. STUDY DESIGN: Between 1982 and 2003, 7 cases of PSTT were treated at the Brewer Trophoblastic Disease Center. Pathology and operative reports, patient records and laboratory results were reviewed. Data collected included patient age, presenting symptoms, human chorionic gonadotropin (hCG) levels, type of antecedent pregnancy, International Federation of Gynecology and Obstetrics (FIGO) stage at diagnosis, mitotic count and immunohistochemical expression of the tumor, treatments, response to treatments and length of survival. RESULTS: The mean age of patients was 34 years. The most frequent presenting symptom was vaginal bleeding (72%). The antecedent pregnancy was a normal, term vaginal delivery in 4 patients, spontaneous or elective abortion in 2 and unknown in 1. The mean interval from last pregnancy to diagnosis of PSTT was 3.2 years (range, 4 months-8 years). Serum hCG levels at the time of diagnosis ranged from 2 to 456 mIU/mL (mean, 130). All patients initially underwent surgery (hysterectomy and/or other procedures), and those with metastatic disease also received chemotherapy (most commonly etoposide, methotrexate, actinomycin D/etoposide, cisplatin [EMA/EP]). The 4 patients with recurrent or advanced disease had additional surgical procedures (thoracotomy, excision of vaginal metastases or laparotomy with intraperitoneal and retroperitoneal disease resection) as well as multiple other types of chemotherapy (e.g., bleomycin, etoposide and cisplatin; ifosfamide, carboplatin and etoposide; carboplatin/paclitaxel). Survival was 57% overall: 75% for the 4 patients with FIGO stage I disease and 33% for the 3 with FIGO stage IV. The 2 patients with mitotic counts < 2 per 10 high power fields survived. Three patients were alive and without evidence of disease for 17 years, 16 years and 8 months; 1 patient was alive with recurrent metastatic disease at 20 months; and 3 patients were dead of disease 13, 30 and 33 months after diagnosis. CONCLUSION: Advanced FIGO stage, long interval from last known pregnancy to diagnosis and high mitotic count were adverse prognostic indicators for survival in PSTT. All patients with PSTT should undergo initial hysterectomy with other surgical procedures, as indicated. Chemotherapy, usually EMA/EP, should be used in patients with advanced PSTT and may be considered in patients with FIGO stage I disease with length of time from antecedent pregnancy > 2 years or high mitotic counts.