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Edited by Ie-Ming Shih, MD, PhD
Division of Gynecologic Pathology
Department of Pathology
Johns Hopkins Medical Institutions
E-mail: ishih@jhmi.edu
Tel: (410) 502-7774
1503 E. Jefferson Street, B-315
Baltimore, MD 21231
Lab website: http://pathology2.jhu.edu/shihlab
Special thanks to Dr. Chih-Yi Hsu for his efforts in photomicrographs and legends
Webmaster; Jennifer Parsons Brumbaugh
Diagnostic pathologists in Gynecological Pathology Division
at the Johns Hopkins Hospital:
Robert J. Kurman, MD, Director
Brigitte Ronnett, MD
Ie-Ming Shih, MD, PhD
Russell Vang, MD
|
Differential Diagnosis- Morphological Basis
Hydatidiform mole v.s. Blighted ovum or hydropic abortus
- Smaller specimen
- Only slightly enlarged villi
- Focal cistern
- No trophoblastic hyperplasia (polar distribution)
Exaggerated Placental Site v.s. Placental Site Trophoblastic Tumor
|
Feature
|
Exaggerated placental site
|
PSTT |
| Gross appearance
|
Not evident
|
Nodule or mass
|
| Cellular population
|
Monomorphic;
implantation site IT
|
Monomorphic;
implantation site IT
|
| Growth pattern
|
Infiltrating |
Confluent sheets or
infiltrating single cells |
| Multinucleated cells
|
Usually abundant |
Occasional
|
| Mitosis
|
Absent |
Variable; 0-6/10HPF
|
| Associated
chorionic villi
|
Usually present
|
Absent |
| Ki-67 labeling index
|
0 |
>10%
|
Exaggerated Placental Site v.s. Placental Site Nodule
|
Feature
|
Exaggerated placental site
|
Placental Site Nodule |
| Cellular population
|
Monomorphic;
implantation site
intermediate trophoblastic
|
Monomorphic;
chorionic-type
intermediate trophoblastic
|
| Cell size and shape
|
Large and pleomorphic
|
Small round and uniform
|
| Cytoplasm
|
Abundant and eosinophilic
|
Eosinophilic or clear
|
| Growth Pattern
|
Infiltrating |
Single cells or small nests or cords |
| Margin
|
Infiltrating |
Circumscribed
|
| Hemorrhage
|
Absent
|
Absent |
| Cellular necrosis
|
Absent |
Absent
|
| Calcification
|
Absent |
Absent
|
| Vascular invasion
|
From periphery to lumen |
Absent
|
| Fibrinoid change
|
Present |
Present
|
| Mitosis
|
Absent |
Absent or extremely rare
|
| Associated
chorionic villi
|
Usually present |
Absent
|
Placental site trophoblastic tumor v.s.
- EPS -
no confluent growth, no mitosis, mixed with decidua & villi
- ETT -
Smaller and uniform cells, expansile margin, extensive necrosis, no vascular invasion
- Choriocarcinoma-
bimorphic population of trophoblastic cells
- Epithelioid smooth muscle tumor, Poorly differentiated carcinoma, Melanoma-
no vascular invasion, no fibrinoid material deposition
PSTT
-
Monomorphic; implantation site
intermediate trophoblastic
- Large and pleiomorphic
- Abundant and eosinophilic cytoplasm
- Infiltrating single cells or
confluent sheets
- Infiltrating margin
- Focal or haphazard hemorrhage
- Usually absent necrosis
- Absent calcification
- Vascular invasion (periphery to lumen)
- Variable mitoses; 0-6/10HPF
|
ETT
- Monomorphic; chorionic-type
intermediate trophoblastic
- Small round and uniform
- Eosinophilic or clear cytoplasm
- Epithelioid nests or cords
or solid masses
- Circumscribed; expansile margin
- Usually present hemorrhage
- Extensive necrosis
- Usually present calcification
- Absent vascular invasion
- Variable mitoses; 1-10/10HPF
|
ETT
|
Squamous Cell Carcinoma
|
Placental Site Trophoblastic Tumor (PSTT) v.s.
Epithelioid Trophoblastic Tumor (ETT), and choriocarcinoma
|
Feature
|
PSTT
|
ETT |
Choriocarcinoma |
| Cellular population
|
Monomorphic;
implantation site
intermediate trophoblastic
|
Monomorphic;
chorionic-type
intermediate trophoblastic
|
Dimorphic;
primitive previllous-type
trophoblast
|
| Cell size and shape
|
Large and pleomorphic
|
Small round and uniform
|
Irregular, highly variable |
| Cytoplasm
|
Abundant and eosinophilic
|
Eosinophilic or clear
|
Eosinophilic to purple
|
| Growth Pattern
|
Infiltrating single cells or
confluent sheets
|
Epithelioid nests or cords
or solid masses |
Dimorphic; mononucleate trophoblast
and syncytiotrophoblast
|
| Margin
|
Infiltrating |
Circumscribed |
Circumscribed, expansile |
| Hemorrhage
|
Focal or haphazard
|
Usually preseent
|
Massive and central |
| Cellular necrosis
|
Usually Absent |
Extensive |
Extensive |
| Calcification
|
Absent |
Usually present |
Absent |
| Vascular invasion
|
From periphery to lumen |
Absent |
From lumen to periphery |
| Fibrinoid change
|
Present |
Present |
Absent |
| Mitosis
|
Variable; 0-6/10HPF |
Variable; 1-10/10HPF
|
High; 2-22/10 HPF |
PSTT
- Neoplasm of implantation site IT
- Reproductive ages, antecedent pregnancy
can be remote
- Abnormal vaginal bleeding
- b-HCG only mildly increased (100-2000 IU/ML)
- Sheets of implantation site IT, local invasion, characteristic BV, lack villi
- Differential diagnosis with EPS, ETT and other uterine tumors
- Most are benign, ~20% are malignant
- Treatment: hysterectomy or local excision
|
ETT
- Neoplasm of chorionic-type IT
- Reproductive ages, antecedent pregnancy
can be remote
- Abnormal vaginal bleeding
- Low serum b-hCG (50 - 500 IU/ML)
- Epithelioid growth, sheets/cords, necrosis
with viable islands, calcification,
lack villi
- Frequently occurs in cervix or LUS
- 15-20% ETTs are malignant
- Hysterectomy or local excision
|
Clinical features of placental site trophoblastic tumor (PSTT), epithelioid
trophoblastic tumor (ETT) and choriocarcinoma
|
Feature
|
PSTT
|
ETT |
Choriocarcinoma |
| Clinical Presentation
|
Missed Abortion
|
Abnormal vaginal bleeding
|
Persistent GTD after hydatidiform mole
|
| Last Pregnancy or GTD
|
Variable, can be remote
|
Variable, can be remote
|
months |
| History of mole
|
5-8%
|
14%
|
50%
|
| Serum hCG
|
Low (< 100-2,000 IU/L)
|
Low (50 - 500 IU/mL)
|
High (>10,000 IU/mL)
|
| Behavior
|
Variable |
Variable |
Aggressive if untreated |
| Response to
chemotherapy
|
Variable
|
Variable |
Good |
| Treatment
|
Surgery
(hysterectomy)
|
Surgery
(hysterectomy)
|
Chemotherapy |
|
|
