Fertility-sparing partial hysterectomy for placental-site trophoblastic tumour.

摘要

A previously healthy 30-year-old woman presented in August 2002 with vaginal bleeding 11 weeks into her first pregnancy. Ultrasound suggested a molar pregnancy and her serum human chorionic gonadotrophin (hCG) concentration was >200 000 IU/L (normal range <4 IU/L). After evacuation, histology showed a complete hydatiform mole. She waa registered with the national Gestational Trophoblastic Disease service for serial monitoring of the hCG concentration over time. 2 months later her hCG concentration had plateaued suggesting malignant change and she was referred to Charing Cross Hospital (London, UK) for further management. On admission, her hCG concentration was 11339 IU/L, Doppler ultrasound of the pelvis showed a vascular focal lesion in the uterus consistent with trophoblastic tumour, and chest radiograph was normal. She started single-agent chemotherapy with intramuscular methotrexate (50 mg on days 1, 3, 5, and 7) alternating with oral folinic acid (15 mg on days 2, 4, 6, and 8) repeated for 2 weeks. The hCG concentration initially fell, but then plateaued at about 1000 IU/L (figure 1) indicating drug resistance. She was switched to combination chemotherapy with etoposide, methotrexate, and dactinomycin, alternating weekly with cyclophosphamide and vincristine. Her hCG concentration briefly normalised, but occasional increases to 8 IU/L during consolidation chemotherapy were noted. The significance of these increases was unclear and treatment was subsequently stopped. Between March and August, 2003, her serum hCG concentration remained raised between 7-24 IU/L (figure 1). Repeat staging investigations during this time, including CT of the body, MRI of the brain, and Doppler ultrasound and MRI of the pelvis, initially only showed increased vasculariry in a small area in the right uterine fundus. However, by July, 2003, repeat MRI and Doppler ultrasound of the pelvis both showed a 2.5 cm right fundal uterine mass associated with the abnormal vascularity. 18-fluorodeoxyglucose ([~(18)F]FDG)-PET was positive in this area with a standardised uptake value of 3.5 ([~(18)F] FDG-PET is valuable for identifying active tumour sites, including those related to gestational trophoblastic tumours). Given the indication of recurrent uterine gestational trophoblastic tumour by imaging and the small increase in hCG concentration, a placental-site trophoblastic tumour was considered possible. Therefore, hysterectomy was discussed with the patient as the treatment of choice for this subtype of trophoblastic disease. However, the patient wished to retain her fertility, so she was started on third-line chemotherapy with gemcitabine (1000 mg/m~2) on days 1 and 8 combined with carboplatin (AUC5) on day 1 repeated every 3 weeks. Her hCG concentration initially rose during the first cycle to 261 IU/L but then fell to 71 IU/L (figure 1). However, MRI of the pelvis in November, 2003, showed an increase in the size of the uterine mass to 3.5 cm (figure 2).