Dr. Shaheen Anjum is a dedicated renowned obstetrician and gynecologist working as an Associate Professor at Jawaharlal Nehru Medical College in Aligarh Muslim University, who fosters learning by evidence-based medicine and has keen interest in preventive oncology, high-risk pregnancy, and geriatric gynecology. Her teaching interest includes clinical teaching, demonstrations, labor management, and imparting surgical skills to post-graduate students.
Exaggerated placental site (EPS) is defined as a non-neoplastic trophoblastic lesion where middle trophoblasts infiltrate exaggeratedly into endometrium and myometrium. It consists of cells showing the same immunophenotypical features as the intermediate trophoblasts in the normal placental implantation site and is observed as an exaggerated form of the normal physiological process [1].
A 45-year-old female presented to our out patient department with continuous bleeding per vaginum for past 3 weeks. The patient had five previous normal vaginal home deliveries, and her last childbirth was 12 years back. Her prior menstrual cycles had been irregular for 3 to 4 months preceding which they were completely normal. Patient had no significant past or family history. On examination, she had significant pallor with stable vital parameters. Her hemoglobin was 6 gm %. Her abdominal examination revealed a 28–30-week smooth firmmasswith restrictedmobility,which seemed tobe arising fromthe pelvis. Her pelvic examination confirmed themass to be mobile with the uterus and was of firm consistency. The patient had active trickling of blood per vaginum. The ultrasound findings revealed a large solid cystic lesion arising from pelvis of approximately 20 9 14 cm, which was not separately visualized from the uterus. On the basis of clinical and radiological findings, differential diagnosis of fibroid uterus was made, and considering her age, the possibility of leiomyosarcoma could not be ruled out. The patient had a normal Chest X-ray & ECG. The patient was advised admission. During the hospital stay, patient was transfused with four units of packed red blood cells to raise hemoglobin. After an informed consent, laparotomy was planned, and total abdominal hysterectomy with bilateral salpingo oophorectomy was done within a week. Specimen revealed a bulky uterus of approximately 18-20 cm.Both the fallopian tubes and ovaries were normal. On Cut section, the large amount of clotted blood was evident within the uterus. Figure 1 shows the gross morphology of the uterus, 20 cm 9 15 cm in size with inset showing cut section, revealing clotted blood. Upon removal of blood clots, an approximately 15 9 15 cm mass was felt on the posterior aspect of uterine wall. Along with the uterus, cervical tissue and ovaries, omental tissue, smears from liver, fluids from paracolic gutter, and pouch of doughlas were sent for histopathology and cytology. The postoperative period was uneventful. Histopathology report disclosed that it was gestational trophoblastic disease with exaggerated placental site reaction. Figure 2 depicts a photomicrograph showing proliferating trophoblastic tissue and chorionic villi, wherein trophoblastic tissue show focus of invasion into the myometrium shown with an arrow and the inset shows high power of invading cells having atypical features. Postoperatively, b hCG was found to be 1094 mIU/ml which was followed up serially. During the follow-up period, the patient was evaluated regularly with hemogram, ultrasound, chest X-ray, and b hCG, which subsided over a period of 5 months after seven chemotherapy cycles with intravenous injection methotrexate 50 mg. The last value done in February 2015 was 2.76 mIU/ml following, which the patient is being followed up every 6 months.
Gestational trophoblastic disease (GTD) is the term used to encompass a group of tumors typified by abnormal trophoblast proliferation. GTD histologically is divided into hydatidiform moles, which are characterized by the presence of villi and non-molar trophoblastic neoplasms, which lack villi. Themalignant forms of gestational trophoblastic disease are termed gestational trophoblastic neoplasia (GTN). These include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor [2]. In this case, a retrospective diagnosis of gestational trophoblastic neoplasia was made. The patient had irregular menses at perimenopausal age group, with pelvic mass, which was confirmed by an ultrasound; thus, fibroid uterus and leiomyosarcoma were kept high in differential diagnosis. An intermediate trophoblast is a distinctive trophoblastic cell population from which four trophoblastic lesions are thought to arise: exaggerated placental site (EPS), placental site nodule (PSN), placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). EPSs and PSNs are non-neoplastic lesions, whereas PSTTs and ETTs are neoplasms with a potential for local invasion and metastasis [3]. The pathological significance of EPS has not been clearly determined. And it is a difficult condition for clinicians to diagnose and has not received much attention until now. In fact, only eleven cases have been reported inEnglish, based on PubMed from 1990 through 2014. EPS has been detected in molar pregnancy, cervical pregnancy, abortion or induced abortion of early pregnancy, intrauterine fetal death of 24 weeks gestation, and term pregnancy. It can develop from early to term pregnancy. In the case with the longest interval from the antecedent pregnancy, a lesion or clinical symptom appeared 15 years after delivery, and in the case with the shortest interval, EPS appeared during pregnancy [4].
Acknowledgments The author would like to acknowledge the cooperation of the patient in the preparation of this manuscript.
Compliance with Ethical Requirements and Conflict of interest Dr, Shaheen, Dr. Kalpana, Dr. Nidhi, and Dr. Nazoora declare that they have no conflict of interest. The authors are responsible for the contents of the manuscript. All of the authors have read and approved the manuscript. Patient’s consent has been taken at every necessary step.
