Surgical Procedures: Surgery and Staging for Placental Site Trophoblastic Disease

Placental site trophoblastic disease (PSTD) is a rare form of a type of uterine disease, called gestational trophoblastic disease (GTD).

Trophoblastic cells make up the placenta during implantation of the embryo in early pregnancy. In PSTD, these trophoblastic cells become cancerous tumors. This form of GTD can happen at any time following a pregnancy, including after a full term pregnancy, a molar pregnancy, ectopic pregnancy, abortion, or miscarriage. In some cases, the condition may not happen for several months or years after a pregnancy.

Most commonly, placental-site trophoblastic tumors invade (grow into) the muscles of the uterus itself and need surgery as treatment. However, it can also spread (metastasize) to other parts of the body.

Diagnosis of PSTD

Once a diagnosis of PSTD has been made or if it is suspected, your healthcare provider will have you get further testing to find the stage of cancer. These tests may include:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. This includes a pelvic exam to check the vagina, cervix, uterus, fallopian tubes, and ovaries. A Pap smear may also be done.

Imaging: Radiology tests can look inside your body to look at the cancer and see if it has spread. These tests can include:

• CAT scan (CT scan).
• Magnetic resonance imaging (MRI).
• Pelvic and/or transvaginal ultrasound.
• Chest X-Ray.

Blood Testing: Some blood tests, such as blood chemistry studies, serum tumor markers (beta human chorionic gonadotropin [β-hCG] and/or human placental lactogen [hPL]), and other bloodwork may be done during workup and treatment.

Urine Testing: Urine testing may be done to check for β-hCG and/or other substances.

Procedures Used to Diagnose PSTD

Some procedures may be done when PSTD is suspected or diagnosed, such as:

• Lumbar Puncture (LP): Cerebrospinal fluid (CSF) is pulled out of the spinal column to see if the cancer has spread or metastasized. A needle, which is placed between two bones in the spine, removes the CSF for testing.
• Dilation and Curettage: The cervix is dilated so that the endometrial tissue, which lines the uterus, can be removed and tested for cancer or other abnormalities. In some cases, a suction device may also be used to remove tissue.

Staging of PSTD

Placental-site trophoblastic disease spreads to other parts of the body by spreading to nearby tissues or traveling through the lymph and blood systems. Cancer stage determines how advanced the cancer is, if and how far it has spread, and how it is treated. Your care team will talk with you about the stage of your disease.

In most cases, you will need surgery. The surgery you have depends on many factors. Your surgeon will talk with you in detail about your procedure.

The most common surgeries are:

• Dilation and Curettage: For some women who desire to have children in the future, a D&C may be an option.
• Hysterectomy:
  • Abdominal: An incision (surgical cut) is made in the abdomen (belly) to remove the uterus. This surgery can have a higher risk of complications and longer recovery time.
  • Vaginal: An incision is made in the upper vagina, and the uterus is removed through the incision. This has less side effects and a faster recovery.
  • Laparoscopic: At times during an abdominal or vaginal hysterectomy, an instrument called a laparoscope will be used. This is a lighted tube with a camera, that allows your doctor to see the pelvic organs without needing a large incision. This procedure requires small incisions in the abdomen where the tool is inserted. Laparoscopic procedures cause less pain, have a lower risk of infection, and a shorter recovery time. However, laparoscopic procedures can take longer to perform and increase the risk of injury to the urinary tract and nearby organs.
  • Robotic: During a robotic procedure, the surgeon controls a robotic arm to perform the surgery through small incisions. This procedure can take longer than the other surgeries.

Note: Your provider will talk with you about whether your cancer is resectable (can be removed with surgery) or unresectable (unable to be removed with surgery). This will help guide the surgical procedure used. There may also be a need to remove other areas of tissue where the cancer has spread.

There may be a need for chemotherapy and/or follow-up testing after surgery. Your care team will talk about these options with you as well.

What are the risks of surgery to treat PSTD?

As with any surgery, there are risks and possible side effects. These can be:

• Bleeding.
• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, to not remember it, and to manage pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Blood clots.
• Infection.
• Cervical scarring (with D&C).

Hysterectomy risks may include:

• Damage to the urinary tract, intestine, or nerves.
• Problems with the wound/incision.
• Injury to the urinary tract and/or nearby organs.
• Nerve damage.
• Bowel blockage (obstruction).

Other risk factors are based on your health and the procedure being done. Speak with your surgeon about the specific risk factors for your case.

What is recovery like?

Recovery from surgery to treat placental-site trophoblastic disease depends on the extent and type of the procedure you have had. A hospital stay may be needed.

You will be taught how to care for your surgical incisions and will be given any other instructions before leaving the hospital.

Your medical team will talk with you about the medications you will be taking, such as those for pain, blood clot, infection, and constipation prevention and/or other conditions.

Your healthcare provider will go over your activity restrictions, depending on the surgery you have had.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.