Combinação rara de neoplasias trofoblásticas gestacionais: caso
                  clínico

A doença trofoblástica gestacional compreende um grupo heterogêneo de lesões decorrentes da proliferação anormal de células trofoblásticas. A elevação da subunidade beta da gonadotrofina coriônica humana (β-hCG) após a evacuação de uma gravidez molar levanta a hipótese diagnóstica de neoplasia trofoblástica gestacional persistente. Apresentamos um caso raro de coexistência de coriocarcinoma e tumor trofoblástico do leito placentário em um mesmo tumor, cujo diagnóstico foi efetuado com base na correlação dos estudos morfológicos, microscópicos e imuno-histoquímicos, dada a dificuldade de diagnosticar esses tumores mistos com base apenas no exame histológico convencional.

coriocarcinoma; gestacional; trofoblasto; neoplasia; quimioterapia

Autoria

Irina Dulce Tapadinhas Matos Ramilo Mailing address: Irina Dulce Tapadinhas Matos Ramilo, Serviço de Ginecologia, Unidade de Ginecologia Oncológica do Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal, IC: 19, 2720-276. e-mail: irinaramilo@gmail.com.

Resident at the Gynecology Service of Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal.Hospital Prof. Doutor Fernando FonsecaPortugalAmadora, PortugalResident at the Gynecology Service of Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal.

Gustavo Martins Mendinhos

Obstetrics and Gynecology specialist at Hospital Prof. Doutor Fernando Fonseca; consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.Hospital Prof. Doutor Fernando FonsecaObstetrics and Gynecology specialist at Hospital Prof. Doutor Fernando Fonseca; consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.

Fernando Antônio Ferreira da Igreja

Physician graduate of Universidade de São Paulo (USP); consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.Hospital Prof. Doutor Fernando FonsecaPhysician graduate of Universidade de São Paulo (USP); consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.

Maria Clara Morais Aleluia

Director of Imaging Services at Hospital Prof. Doutor Fernando Fonseca.Hospital Prof. Doutor Fernando FonsecaDirector of Imaging Services at Hospital Prof. Doutor Fernando Fonseca.

Rosete Maria Amorim Novais Nogueira

Visiting assistant professor at Escola de Ciências da Saúde/Instituto de Ciências da Vida e da Saúde, Universidade do Minho, Braga, Portugal; director at the Anatomical Pathology Laboratory of Centro de Genética Clínica, Porto, Portugal.Centro de Genética ClínicaPortugalPorto, PortugalVisiting assistant professor at Escola de Ciências da Saúde/Instituto de Ciências da Vida e da Saúde, Universidade do Minho, Braga, Portugal; director at the Anatomical Pathology Laboratory of Centro de Genética Clínica, Porto, Portugal.

Fernando Manuel Ribeiro Gomes

José Manuel Silva Pereira

Director of the Gynecology Service of Hospital Prof. Doutor Fernando Fonseca; lead consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.Hospital Prof. Doutor Fernando FonsecaDirector of the Gynecology Service of Hospital Prof. Doutor Fernando Fonseca; lead consultant at the Gynecologic Oncology Unit of Hospital Prof. Doutor Fernando Fonseca.

Mailing address: Irina Dulce Tapadinhas Matos Ramilo, Serviço de Ginecologia, Unidade de Ginecologia Oncológica do Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal, IC: 19, 2720-276. e-mail: irinaramilo@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Director of Imaging Services at Hospital Prof. Doutor Fernando Fonseca.Hospital Prof. Doutor Fernando FonsecaDirector of Imaging Services at Hospital Prof. Doutor Fernando Fonseca.

Consultant at the Medical Oncology Service of Hospital Prof. Doutor Fernando FonsecaHospital Prof. Doutor Fernando FonsecaConsultant at the Medical Oncology Service of Hospital Prof. Doutor Fernando Fonseca

Figuras | Tabelas

Figuras (3)
Tabelas (1)

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FIGURE 1
Time evolution of serum β-hCG levels (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal)

β-hCG: beta subunit of human chorionic gonadotropin.

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FIGURE 2
Gynecologic ultrasound image and surgical specimen of the clinical case (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal)

In the gynecologic ultrasound image, a hypervascularized central area of heterogeneous structure is visible, infiltrating the anterior and posterior wall of the uterine myometrium. Surgical specimen of hysterectomy with conservation of adnexa.

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FIGURE 3
Histological examination (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal and Centro de Genética Clínica, Porto, Portugal)

Post-molar trophoblastic neoplasia: A) HE, villi with marked edema with formation of cistern with acellular center, without blood vessels, absence of normal villi; B) marked proliferation of trophoblast, positivity for β-hCG (+++); C) PLAP (+).

Endomyometrial invasive lesion: D-H) HE, CC component with pleomorphism and acellular atypia, mitoses (arrow), polarization to vascular structures (arrow head), hemorrhage and necrosis.

Immunohistochemical profile: I) strongly marked β-hCG (+++); J) strongly expressed AE1/ AE3 (+++), straight muscle fibers with weak expression for epithelial markers and in the PSTT component; L) weakly marked inhibin (+); M) moderately marked PLAP (++).

HE: hematoxylin and eosin; β-hCG: beta subunit of human chorionic gonadotropin; PLAP: placental alkaline phosphatase; CC: choriocarcinoma; PSTT: placental-site trophoblastic tumor.

Thumbnail

TABLE
Anatomical staging of GTN (FIGO)

FIGURE 1 Time evolution of serum β-hCG levels (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal)
β-hCG: beta subunit of human chorionic gonadotropin.

FIGURE 2 Gynecologic ultrasound image and surgical specimen of the clinical case (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal)
In the gynecologic ultrasound image, a hypervascularized central area of heterogeneous structure is visible, infiltrating the anterior and posterior wall of the uterine myometrium. Surgical specimen of hysterectomy with conservation of adnexa.

FIGURE 3 Histological examination (Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal and Centro de Genética Clínica, Porto, Portugal)
Post-molar trophoblastic neoplasia: A) HE, villi with marked edema with formation of cistern with acellular center, without blood vessels, absence of normal villi; B) marked proliferation of trophoblast, positivity for β-hCG (+++); C) PLAP (+).

Endomyometrial invasive lesion: D-H) HE, CC component with pleomorphism and acellular atypia, mitoses (arrow), polarization to vascular structures (arrow head), hemorrhage and necrosis.

Immunohistochemical profile: I) strongly marked β-hCG (+++); J) strongly expressed AE1/ AE3 (+++), straight muscle fibers with weak expression for epithelial markers and in the PSTT component; L) weakly marked inhibin (+); M) moderately marked PLAP (++).

HE: hematoxylin and eosin; β-hCG: beta subunit of human chorionic gonadotropin; PLAP: placental alkaline phosphatase; CC: choriocarcinoma; PSTT: placental-site trophoblastic tumor.

TABLE Anatomical staging of GTN (FIGO)

Stage I	Disease confined to the uterus
Stage II	Disease extends outside the uterus, although limited to genital structures (adnexa, vagina and broad ligaments)
Stage III	Lung metastases, with or without known involvement of genital tract
Stage IV	All other metastatic sites

GTN: gestational trophoblastic neoplasia; FIGO: International Federation of Gynecology and Obstetrics.

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Combinação rara de neoplasias trofoblásticas gestacionais: caso clínico

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[1] Mailing address: Irina Dulce Tapadinhas Matos Ramilo, Serviço de Ginecologia, Unidade de Ginecologia Oncológica do Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal, IC: 19, 2720-276. e-mail: irinaramilo@gmail.com.