Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide

Gestational trophoblastic neoplasia(GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma(CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor(PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases.The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics(FIGO)2000 criteria: four or more plateaued human chorionic gonadotropin(hCG)concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However,the latter reason for treatment is no longer used by many centers. In addition,GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate(MTX) or Actinomycin-D(Act-D), can cure about 70% of patients with FIGO/World Health Organization(WHO) prognosis risk score ≤ 6(low risk), reserving multiple agent chemotherapy, such as EMA/CO(Etoposide,MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7(high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death,allow the healing and maintenance of the reproductive potential of these women.

Illness Perception in Gestational Trophoblastic Disease Patients: How Mental Representations Affect Anxiety, Depression, and Infertility-Related Stress

Gestational Trophoblastic Disease encompasses a group of pregnancy-related disorders that derive from the placenta. Taking Leventhal’s Common Sense Model as a starting point, this study aims to investigate how illness perception could influence patients’ psychological adaptation to these rare diseases. Thirty-seven women completed: the Illness Perception Questionnaire-Revised, the Beck Depression Inventory Short Form, the State-Trait Anxiety Inventory, and the Fertility Problem Inventory. Results show that the perception of severe illness consequences significantly predicts the level of anxiety patients reported at the time of questionnaire completion. Furthermore, mental representations of illness present a significant association with infertility-related stress. Specifically, the belief in the efficacy of the treatment results in fewer feelings of discomfort and isolation from family and social context due to infertility-related problems. Since patients’ illness perception was found to have a specific impact on both anxiety and infertility-related stress, this variable should be considered in the planning of a clinical intervention.

DIAGNOSIS AND TREATMENT OF THE MALIGNANT GESTATIONAL TROPHOBLASTIC TUMOR WITH PULMONARY METASTASIS COMPLICATED WITH PULMONARY TUBERCULOSIS

Objective. To evaluate the diagnosis and treatment for malignant gestational trophoblastic tumor(MGTT) with pulmonary metastasis complicated with pulmonary tuberculosis. Methods. To analyze ten cases of MGTT with pulmonary metastasis complicated with pulmonary tuberculosis in our hospital from 1980 to 1997 retrospectively. Results.From the x ray film, there are great resemblances between MGTT with pulmonary metastasis and pulmonary tuberculosis. Of 10 patients, 7 of them were examined out pulmonary tuberculosis during the chemotherapy of MGTT. Pulmonary tuberculosis appeared six months before chemotherapy in three cases. All of the patients were treated with multiagent chemotherapy. Seven patients achiceved a complete remission, 2 patients developed drug resistance and died of cerebral haemorrhage and cerebral herniation, 1 woman who had achieved a complete remission from MGTT for 14 months died of miliary tuberculosis. Conclusion. It is very important to make differential diagnosis of the MGTT with pulmonary metastasis complicated with pulmonary tuberculosis. Trying to avoid excessive anti tumor treatment owing to mistake pulmonary tuberculosis for pulmonary metastasis, and avoiding missing an opportunity of anti tuberculosis treatment because of missed diagnosis should be emphasized.

How and Why Do Gestational Trophoblastic Neoplasms Overproduce Human Chorionic Gonadotropin?

From the published data, the present mini-review attempts to answer two fundamental questions about the gestational trophoblastic neoplasms. In addition, it extrapolates the findings to other cancers that produce small amounts of hCG and how a novel therapies could be developed.

EMA/CO Regimen Chemotherapy for Gestational Trophoblastic Tumor

Objective To evaluate the efficacy and safety of etoposide, methotrexate, actinomycin D, vincristine and cyclophosphamide (EMA/CO) therapy for gestational trophoblastic tumor (GTT). Methods Medical records of all patients with low risk, middle risk and high risk GTT receiving EMA/CO regimen chemotherapy were analyzed retrospectively. Results\ Twenty one low risk and fourteen middle risk GTT received EMA/CO with 100% remission, six patients with high risk GTT received EMA/CO with 83% complete response and with 17% partial response; Gastrointestinal, hematologic and hepatic toxicity, as well as shed of hair is predictable, mild and reversible. Conclusion\ At present EMA/CO chemotherapy is the choice of our treatment for patients with high, middle and low risk GTT.\;

Macroscopic hematuria as a presentation of gestational trophoblastic neoplasia in an adolescent woman

Gestational trophoblastic neoplasia (GTN) is a hemorrhagic malignancy with highly rapid potential metastasis via hematogenous spreading. Renal metastasis is of infrequent occurrence. Among previous case reports of renal metastasis in GTN, this is the youngest woman presenting a large renal lesion concurrent with pulmonary and brain metastases. Disease remission had been achieved by treatment with combined chemotherapy and whole brain radiation, although acute myeloblastic leukemia (AML) developed later.

A rare cause for gestational trophoblastic neoplasia: Placental site trophoblastic tumor

Placental site trophoblastic tumor is a rare sub-group of gestational trophoblastic neoplasia. There is a wide clinical spectrum of presentation and behaviour ranging from a benign condition to an aggressive disease with a fatal outcome. We report a case of placental site trophoblastic tumor in 23-year-old women with irregular vaginal bleeding during postpartum lactation period. In addition to persistent low level β-hCG titers, ultrasound examination revealed a suspicious low-echoic area in the myometrium consistent with gestational trophoblastic disease. After histopathological examination of the specimen achieved by ultrasound-guided dilatation and curettage of the uterus, the placental site trophoblastic tumor diagnosis was made and subsequently total abdominal hysterectomy was performed. The patient had an uneventful recovery, and no recurrence was detected for 40 months in the follow-up period.

Gestational Trophoblastic Neoplasia: Clinical and Therapeutic Profile in Madagascar

Gestational trophoblastic disease (GTD) develops from abnormal cellular proliferation of trophoblasts following fertilization. This includes complete and partial hydatidiform mole (HM) and gestational trophoblastic neoplasia (GTN). The aim of this study was to report the epidemiological, clinical and therapeutic profile of gestational trophoblastic neoplasia (GTN) over period of ten years in the department of Oncology Radiotherapy at the University Hospital Joseph Ravoahangy Andrianavalona (HJRA) Antananarivo Madagascar. Medical records of women diagnosed with GTD in the department of Oncology Radiotherapy at HJRA from January 1st, 2007 to September 2017 were retrospectively reviewed. Only patients with the FIGO diagnosis GTN were included, while those with the histological diagnosis of hydatidiform mole (HM), also sometimes classified as GTD, were not included in this study. Also excluded were all cases with incomplete or missing data. Twenty four patients were included. Median age of patients at the time of diagnosis was 37 years (range 18 - 60). Most patients developed GTN following molar pregnancy (75%), had disease duration from antecedent pregnancy of less than 6 months (58.20%), and had the pre-treatment hCG level more than 10,000 IU/L (58.27%). At diagnosis, 14 patients (58.33%) had localized disease (M0). Most common metastatic sites at initial diagnosis were the liver and brain (20.83%). After a median follow-up from initial diagnosis of six months (range 1 - 24), 58.33% were lost to follow up. This represented an increase in the percentage of patients lost to follow up prior to completion of therapy, when compared with our previous results for an earlier time period. GTN in Malagasy woman displays an aggressive clinic profile. Finding ways to increase treatment compliance provides the best way to minimize recurrences of this potentially deadly disease.

Chemo-resistant gestational trophoblastic neoplasia, 5-years experience of Mansoura University Hospital, Egypt

Introduction: Gestational trophoblastic neoplasia (GTN), is recognized as the most curable gynaecologic malignancy. However, many cases are resistant to first line chemotherapy. Objective: The aim of the study is to report our 5 years experience in the management of GTN cases with special stress on the chemo-resistant cases. Methods: The study was performed through reviewing the records of 51 patients who were diagnosed as GTN during the period from 1/1/2006 to 31/12/2010 in Mansoura University Hospital, Egypt. Results: Resistance to methotrexate therapy was reported in 15.15% of low risk cases and received etoposide or cisplatinum/etoposide. Sixty percent of high risk cases were resistant to MAC combination and received salvage chemotherapy or hysterectomy. There was significant correlation between patient response and initial B-hCG, as well as WHO risk score (P value = 0.001 in both) but correlations with age, parity, type of antecedent pregnancy, and histopathology were non significant (p = 0.95, 0.53, 0.47& 0.83 respectively). Conclusion: Low risk GTN cases who were resistant to methotrexate monotherapy received etoposide or cisplatinum/etoposide as a second-line therapy. High risk GTN cases who were resistant to MAC combination received second-line combination chemotherapy and/or hysterectomy. WHO risk score and initial B-hCG were correlated to resistance to first line chemotherapy.

Doppler Ultrasound in Post-Molar Gestational Trophoblastic Neoplasia

Objectives: To evaluate the role of Doppler ultrasound in prediction and follow up during management of gestational trophoblastic neoplasia (GTN). Methods: The study was performed at Oncology Unit, Maternity Hospital, Ain Shams University in the period from November 2015 to December 2018. Forty cases of complete mole, after evacuation and follow up of serum human chorionic gonodotrophin (β-hCG) titre until it reached zero level (group I) and forty post molar GTN cases (group II) were included in the study. Doppler ultrasound of the subendometrial and intramural blood flow was done for all cases of group I and II. Doppler included two dimensional and three dimensional power Doppler indices. Group II received Methotrexate (MTX) and folinic acid in a dose of 8-day MTX-FA regimen. Doppler follow up for six months of group II concurrently with the chemotherapy regimen was done. Results: A statistically significant difference was found between group I and II regarding initial readings of all Doppler parameters. Follow up for 6 months of GTN cases revealed progressive statistically significant decrease of intramural and subendometrial three dimensional power Doppler (3DPD) indices, while there was a significant increase in two dimensional (2D) Doppler parameters. Four cases were resistant to Methotrexate chemotherapy. Cut off values were determined for prediction of GTN. Multivariate analysis revealed that the most predictive parameter was the subendometrial pulsatility index (PI), odds ratio = 10.63 (95% CI: 1.30 - 86.89). The cut-off point for sub-endometrial PI was: 2.05 (AUC, 90%;sensitivity, 88%;specificity, 76%, PPV 78%, and NPV 86%) with a diagnostic accuracy of 87%. To and Fro sign may be considered a pathognomonic intramural ultrasound sign for prediction of GTN chemo-resistance or choriocarcinoma. Conclusion: Cut off values for Doppler parameters can be used for early predication of GTN. Doppler ultrasound indices can be used during follow up of GTN cases concurrently with serum β-hCG to monitor the response to treatment.

Expression of epidermal growth factor and its receptor in gestational trophoblastic diseases

Objective: To determine whether epidermal growth factor (EGF) and its receptor have any possible correlation with etiology of gestational trophoblastic diseases. Methods: Avidin-biotin immunoperoxidase techniques with polyclonal antibodies against EGF, EGFR were used to examine 53 cases of GTD, including complete hydatidiform mole(16),invasive mole(20),gestational choriocarcinoma(17).Results:EGF was mainly localized on syncytiotrophoblasts (ST), and was found less on cytotrophoblasts. Cytologic localization of EGFR showed the similar results. The positive rate of EGF and EGFR were 0.625, 0.813 in hydatidiform mole, 0.405, 0.450 in invasive mole and 0.118, 0.235 in gestational choriocarcinoma. There was significant difference of EGF or EGFR among hydatidiform mole group and other groups, respectively (P<0.05). Conclusion:The cellular levels of EGF and EGFR decreased gradually in the development of GTD. It implied that the autocrine and paracrine mechanism may play an important role on the proliferation and differentiation of trophoblast cells and the disorder of the system may lead to GTD malignant transformation.

Efficacy and Risk Factors Associated to Resistance to Single-Agent Chemotherapy in Low-Risk Gestational Trophoblastic Neoplasia

Objectives: This study aimed to assess efficacy of intramuscular methotrexate 8-day protocol in the treatment of low-risk gestational trophoblastic neoplasia and also identify prognostic factors associated with treatment failure, necessitating second line chemotherapy. Methods: This study was performed at Gynaecologic and Obstetric Clinic of Dakar Teaching Hospital, the reference Centre of Gestational Trophoblastic Disease in Senegal. At the beginning of 2011, patients were followed according to FIGO’s recommendations. From 2011 to 2014, we diagnosed 88 low-risk gestational trophoblastic neoplasia (GTN) patients (WHO score < 7). Low-risk patients started their treatment with methotrexate (MTX) based on the 8-day protocol consisting of 1 mg/kg MTX in combination with 0.1 mg/kg folinic acid (FA) every other day. Resistance to treatment was the main outcome. We studied the association of different prognostic factors included in the World Health Organisation (WHO) scoring system and resistance to the initial single agent chemotherapy. Results: Eighty-eight patients were diagnosed for GTN during the study period. Average age was 31 years. The antecedent pregnancy was molar in 98.1% of cases. Seventy-four patients underwent remission after single agent-chemotherapy. Resistance rate to single-agent chemotherapy was 15.9% (14 patients). Nine of them achieved remission after second line chemotherapy. WHO score was significantly associated with the risk of resistance to single-agent chemotherapy. Other variables included in the WHO as age, antecedent pregnancy, pre-treatment hCG, tumour size and FIGO stage were not significantly associated with resistance. We report five fatal cases. Conclusion: The 8-day protocol consisting of 1 mg/kg MTX in combination with 0.1 mg/kg folinic acid (FA) every other day is effective for women with LRGTN. The only significant prognostic factor for failure is pretreatment WHO score. We highly recommend the use of this protocol particularly in developing countries where methotrexate is available, affordable and relatively safe.

EXPRESSION OF P53 PROTEIN AND PROLIFERATING CELL NUCLEAR ANTIGEN IN HUMAN GESTATION TROPHOBLASTIC DISEASE

To study the relationship between p53 protein, proliferating cell nuclear antigen (PCNA) expression and benign or malignant gestational trophoblastic disease (MGTD). Methods: The histotomic sections of 48 patients with gestational trophoblastic disease and 24 patients of normal chorionic villi were stained using immunohistochemistry. The monoclonal antibodies were used to determine p53 protein and PCNA. Results: The frequency of p53 and PCNA positive expression were significantly different among the chorionic villi of normal pregnancy, hydratidiform mole (HM) and MGTD. But neither p53 nor PCNA has any relation with the clinical staging or metastasis of MGTD. Conclusion: Both P53 and PCNA are valuable in diagnosis of human gestational trophoblastic disease.

Uterine epithelioid trophoblastic tumor with the main manifestation of increased human chorionic gonadotropin:A case report

BACKGROUND Epithelioid trophoblastic tumor(ETT)is an extremely rare malignant gestational trophoblastic neoplasm commonly presenting with abnormal vaginal bleeding,abdominal pain,and increased human chorionic gonadotropin(hCG).This study reported a case of uterine ETT with the main manifestation being increased hCG.CASE SUMMARY A 39-year-old female was referred to the Ningbo Maternal and Child Hospital of China in December 2022,complaining of increased hCG levels for 1 month.Magnetic resonance imaging revealed gestational trophoblastic tumor,and hysteroscopic electrotomy and curettage of intrauterine hyperplasia were performed.The patient was diagnosed with uterine ETT through postoperative pathological examination and immunohistochemical results.Total laparoscopic hysterectomy and bilateral salpingectomy were performed,and hCG levels returned to normal.The patient was without recurrence during the postoperative 3-month follow-up.CONCLUSION This study reported a case of uterine ETT with the main manifestation being increased hCG,highlighting that ETT should be considered in the presence of abnormal hCG.A total laparoscopic hysterectomy is recommended.

Metastasia Lesion of Gestation Trophoblastic Tumor in Abdominopelvic Cavity Diagnosed by Sonographic and Doppler Imaging

Objective: The purpose of this study was to review clinical data of metastasia lesion of gestation trophoblastic tumor (GTT) in abdominopelvic cavity by color Doppler ultrasound. Subjects and Methods: A retrospective analysis of 13 cases of GTT in China was performed. Clinical appearances, serum human chorionic gonadotropin (hCG) levels, sonographic findings, Doppler waveforms, and patient outcomes were followed up. Color Doppler ultrasound was performed to diagnose the presence of GTT, detect metastasia lesion in abdominopelvic cavity, assess disease recurrence, and monitor the efficacy of chemotherapy. Results: Of the 13 patients with GTT, 4 had choriocarcinoma which 3 cases occurred after an abortion, 1 after a year of dilation and suction evacuation for the hydatidform mole. Metastasia lesion in abdominopelvic cavity was detected by color Doppler ultrasound in all cases of choriocarcinoma, among which the metastasia lesion were found at uterine fundus, near uterus, colon and cystic vascular space near the uterus, repectively. 9 cases with an invasive hydatidiforn mole (IHM) occurred after one to three months of dilation and suction evacuation for the hydatidform mole, consistant with the hCG levels markedly elevating. Metastasia lesion in abdominopelvic cavity was also detected by color Doppler ultrasound besides invasive lesion in uterine muscular layer in all cases of IHM, among which 3 cases showed metastasia lesion in cystic vascular space near the uterus, 2 cases were detected in side wall of pelvic cavity, while the rest were found in abdominal cavity, right kidney, colon and near uterus, respectively. Meanwhile, the image of metastasia lesion with IHM was similar to choriocarcinoma’s. And the reticular structure, the cystic vascular space and solid lesion may be showed by ultrasound. The metastasia lesion had abundant flow. Doppler waveforms showed resistive indices of 0.34 (SD 0.07) for metastasia lesion. There was the same lower-impedance as invasive lesion in uterine muscular layer. Except an IHM with the renal metastasia lesion having been followed, abnormal sonographic and Doppler findings in other metastasia disease all disappeared after surgical operation or chemotherapy were successful. Conclusions: Sonography and Doppler imaging were helpful in detecting metastasia lesion in abdominopelvic cavity, and in following the effectiveness of chemotherapy. And it should be taken full examination for GTT by Color Doppler ultrasound in order to avoid mistake.

Updates in the Diagnosis of Gestational Trophoblast Disease

GTD (Gestational Trophoblastic Disease) is a pathology that encompasses benign and malignant clinical forms, affects women of childbearing age, has a variable incidence and is more frequent in developing or underdeveloped countries, colliding with the economic barrier. The frequent absence of clear protocols and guidelines for the correct diagnosis of the pathology results in inadequate classification, imprecise treatment and failed post-therapeutic observation, increasing the risk of relapses, morbidity and mortality. The present study aims to point out updated national and international practice protocols of diagnosis of GTD, through an integrative review. Seven articles were selected and it was observed that the main international reference centers are agreed with the management suggested by the IFGO (International Federation of Gynecology and Obstetrics), being the conduct in the Hydatidiform Mole (HM): evacuation by suction and curettage under ultrasound guidance, followed by hCG monitoring every 1 - 2 weeks until normalized (usually one month for Partial Hydatidiform Mole six months for Complete Hydatidiform Mole and one year for Gestational Trophoblastic Neoplasia). Unfortunately, regarding the diagnosis of MH, the guidelines of some countries show the absence or difficulty of access to the karyotype test and ploid p57 or pelvic ultrasound accompanying the uterine curettage, contrary to what is proposed by the IFGO guideline. Establishing and complying with consistent guidelines can improve patient care, with early diagnosis of the pathology and its complications, reducing the rate of recurrence, morbidity and mortality, especially in less developed countries.

Management of Gestational Trophoblast Disease: A Review Integrative National and International Guidelines

GTD (Gestational Trophoblastic Disease) is a pathology that encompasses benign and malignant clinical forms, affects women of childbearing age, has a variable incidence and is more frequent in developing or underdeveloped countries, colliding with the economic barrier. The frequent absence of clear protocols and guidelines for the correct diagnosis and treatment of the aforementioned pathology results in inadequate risk classification, imprecise treatment and failed post-therapeutic observation, increasing the risk of relapses, morbidity and mortality. The present study aims to compare the different national and international guidelines in the management of GTD, through an integrative review. Nine articles were selected and it was observed that the main international reference centers are agreed with the management suggested by the IFGO (International Federation of Gynecology and Obstetrics), being the conduct in the Hydatidiform Mole (HM): evacuation by suction and curettage under ultrasound guidance, followed by hCG monitoring every 1 - 2 weeks until normalized;in low-risk GTN (Gestational Trophoblastic Neoplasm): chemotherapy with methotrexate or actinomycin D, in high-risk: EMA/CO protocol, in ultra-high-risk EMA/PE, methotrexate with radiotherapy for brain metastases. All medical societies recommend the registration of these patients in GTD screening centers, endorse the use of the IFGO scoring system (2000) and recommend the surgical management of placental site trophoblastic or epithelioid tumors, as chemotherapy is less effective in these cases. The controversies are in the proper follow-up after the treatment of HM, use of ultrasound to evacuate the uterus, administration of anti-D immunoglobulin, time of oxytocin infusion and rescue regimens that can be used in cases of resistant or recurrent GTN. Establishing and complying with consistent guidelines can improve patient care, with early diagnosis of the pathology and its complications, reducing the rate of recurrence, morbidity and mortality, especially in less developed countries.

The Role of Ultrasound in the Diagnosis and Management of Trophoblastic Diseases (TMD) at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou

Objective: To describe the place of ultrasound in the diagnosis and management of Gestational Trophoblastic Diseases (GTD) at the Ouagadougou UTH-YO, Ouagadougou, Burkina Faso. Materials and Patients: It was a prospective and descriptive study over a 3-year period from 1 January 2015 to 31 December 2017. It took place in the gynecology and obstetrics department of at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou. Monitoring was based on clinical examination data, ultrasound and kinetics of β-gestational chorionic hormone (GCH) levels. Results: During the study period, we recorded 34 cases of trophoblastic diseases. The average age of the patients was 35 years with extremes of 22 and 52 years. Physical examination revealed a uterus larger than gestational age in 17 patients (56.67%) of cases. Eight (26.67%) patients were asymptomatic. The initial mean β-GCH was 453,747.8 IU/l with extremes of 5903 IU/l and 1,890,000 IU/l. Ultrasound was used to evoke the diagnosis in 23 patients, that to say 76.67% of the cases. Ultrasound identified 10 complete mole cases, 20 partial mole cases. For the 3 cases of invasive mole, pelvic ultrasound revealed heterogeneous intrauterine multi-vesicular images. In a case of choriocarcinoma, ultrasound found an enlarged uterus with a poorly limited intracavitary heterogeneous fundic image. Conclusion: This short series shows the central role of ultrasound in the diagnosis and follow-up of gestational trophoblastic diseases. Indeed, the sensitivity of ultrasound is excellent in the early diagnosis of complete moles. Ultrasonography remains a good examination choice for the diagnosis of gestational trophoblastic tumors despite their great polymorphism. The place of ultrasound in prognostic evaluation and treatment monitoring deserves to be studied by more important series.

Epithelioid trophoblastic tumor of the lower uterine segment and cervical canal:A case report

BACKGROUND Epithelioid trophoblastic tumor(ETT) is the rarest type of gestational trophoblastic tumor(GTT). It has been reported that more than 50% of ETTs arise in the uterine cervix or the lower uterine segment. Here, we report a case of ETT within the lower uterine segment and cervical canal and discuss its manifestations,possible causes, and related influencing factors.CASE SUMMARY A 35-year-old woman(gravida 7, miscarriage 3, induction 2 with 1 being twins,para 2 of cesarean section, live 2), who had amenorrhea for 9 mo after breastfeeding for 22 mo after the last cesarean section, was diagnosed with ETT. The lesion was present in the lower uterine segment and endocervical canal with severe involvement of the anterior wall of the lower uterine segment and the front wall of the lower uterine segment where the cesarean incisions were made.Laboratory tests showed slight elevation of serum beta-human chorionic gonadotropin. Intraoperative exploration showed the presence of a normal-sized uterus body with an enlarged tumor in the lower uterine segment. The surface of the lower uterine segment was light blue, the entire lesion was approximately about 8cm × 8 cm × 9 cm, with compression and displacement of the surrounding tissue.Histological examination diagnosed ETT. Immunohistochemical analysis showed positive expression of p63, with a Ki-67 proliferation index of 40%.CONCLUSION A search of the PubMed database using the search terms "cesarean section" and "epithelioid trophoblastic tumor" retrieved nine articles, including 13 cases of ETT and ETT-related lesions, all 13 cases had a history of cesarean section, and the lesions were all located at the cesarean section incision on the anterior wall of the lower uterine segment. The present case is the 14th reported case of ETT after cesarean section. Therefore, we deduced that cesarean section trauma had an important effect on the occurrence of ETT at this site.

Chemotherapy initiation with single-course methotrexate alone or combined with dactinomycin versus multi-course methotrexate for low-risk gestational trophoblastic neoplasia: a multi-centric randomized clinical trial

We aimed to evaluate the effectiveness and safety of single-course initial regimens in patients with low-risk gestational trophoblastic neoplasia(GTN).In this trial (NCT01823315),276 patients were analyzed.Patients were allocated to three initiated regimens:single-course methotrexate(MTX),single-course MTX+dactinomycin(ACTD),and multi-course MTX(control arm).The primary endpoint was the complete remission(CR)rate by initial drug(s).The primary CR rate was 64.4%with multi-course MTX in the control arm.For the single-course MTX arm,the CR rate was 35.8%by one course;it increased to 59.3%after subsequent multi-course MTX,with non-inferiority to the control(difference-5.1%,95%confidence interval(CI)-19.4%to 9.2%,P=0.014).After further treatment with multi-course ACTD,the CR rate(93.3%)was similar to that of the control(95.2%,P=0.577).For the single-course MTX+ACTD arm,the CR rate was 46.7%by one course,which increased to 89.1%after subsequent multi-course,with non-inferiority(difference 24.7%,95%CI 12.8%-36.6%,P<0.001)to the control.It was similar to the CR rate by MTX and further ACTD in the control arm(89.1%vs.95.2%,P=0.135).Four patients experienced recurrence,with no death,during the 2-year follow-up.We demonstrated that chemotherapy initiation with single-course MTX may be an alternative regimen for patients with low-risk GTN.