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 or GTD. These cancerous tumors form from the trophoblastic cells, which make up the placenta during the process of implantation. This form of GTD can occur 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 does not occur for several months or years following a pregnancy.
Most commonly placental-site trophoblastic tumors invade into the muscular layer of the uterus itself and require surgery as treatment. However, it can also spread to other parts of the body.
Diagnosis of PSTD
Once a diagnosis of placental-site trophoblastic disease has been made or if there is suspicion that the disease is present, your healthcare provider will typically obtain additional testing to determine 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 evaluate 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 determine 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: Certain blood tests such as blood chemistry studies, serum tumor markers (beta human chorionic gonadotropin (β-hCG) and/or human placental lactogen (hPL) and other blood work may be done during the workup and treatment phases.
Urine Testing: Urine testing may be done to check for β-hCG and/or other substances.
Procedures Used in the Diagnosis of PSTD
Certain procedures may be done during the initial evaluative phase (often called “work-up”), such as:
- Lumbar Puncture: During a lumbar puncture (LP) or spinal tap, cerebrospinal fluid (CSF) is extracted from 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 evaluation.
- Dilation and Curettage: The cervix is dilated so that the endometrial tissue, which lines the uterus, can be removed and evaluated 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 extensive the cancer is, how far it has spread, and helps determine what treatment course will be recommended. Your oncologist will discuss with you the stage of your disease.
In most cases, surgery will be recommended. The surgical procedure recommended depends on several factors. Your surgeon will discuss with you in detail the recommended procedure.
The most common surgeries include:
- Dilation and Curettage: For some women who desire to have children in the future, a D&C may be an option, however, is not always possible.
- Hysterectomy: Removal of the uterus. This can be done in a few different ways:
- Abdominal: An incision is made in the abdomen to remove the uterus; this approach 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 approach offers fewer complications 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, which allows for your doctor to see the pelvic organs without needing a large incision. This procedure requires small incisions in the abdomen where the tool(s) is inserted. The laparoscopic approach is associated with less pain, 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 surrounding 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 traditional approach.
Note: Your surgeon will discuss with you if your cancer is resectable (surgically removable) or unresectable (likely unable to be removed with surgery), which will determine the surgical procedure recommended. There may also be a need to remove other areas where the cancer has spread.
There may be a need for chemotherapy and/or follow-up testing after surgery. Your oncologist will discuss these recommendations with you as well.
What are the risks associated with surgery to treat Placental-Site Trophoblastic Disease?
As with any surgery, there are risks and possible side effects. These can be:
- Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it and manage pain. Reactions can include wheezing, rash, swelling and low blood pressure.)
- Blood clots.
- Cervical scarring (D&C specific).
Risks specific to hysterectomy may include:
- Damage to the urinary tract, intestine or nerves.
- Wound complications.
- Injury to the urinary tract and/or surrounding organs.
- Nerve damage.
- Bowel obstruction.
Other risk factors are determined based on your health and the procedure being performed. 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 will depend 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 discuss with you 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 discuss 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.
Surgery for Gestational Trophoblastic Disease (February 9, 2016) Retrieved from https://www.cancer.org/cancer/gestational-trophoblastic-disease/treating/surgery.html
What Is Gestational Trophoblastic Disease? (February 9, 2016) Retrieved from https://www.cancer.org/cancer/gestational-trophoblastic-disease/about/what-is-gtd.html
Placental site trophoblastic tumour. Retrieved from http://www.cancerresearchuk.org/about-cancer/gestational-trophoblastic-disease-gtd/placental-site-trophoblastic-tumours-pstts
Gestational Trophoblastic Disease Treatment (PDQ®)–Patient Version. Retrieved from https://www.cancer.gov/types/gestational-trophoblastic/patient/gtd-treatment-pdq
Kim, SJ. Placental site trophoblastic tumour. Best Pract Res Clin Obstet Gynaecol. 2003 Dec;17(6):969-84. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14614893
Gestational Trophoblastic Disease Treatment (PDQ®)–Patient Version. Retrieved from https://www.cancer.gov/types/gestational-trophoblastic/patient/gtd-treatment-pdq#section/_21
Gestational Trophoblastic Disease Treatment (PDQ®)–Health Professional Version (February 25, 2015 ) Retrieved from https://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq#section/_92
Dilation and Curettage (D&C). (February 2016) Retrieved from https://www.acog.org/Patients/FAQs/Dilation-and-Curettage-DandC#is
Surgical Procedures: Hysterectomy. (November 23, 2015) Retrieved from http://www.oncolink.org/cancers/gynecologic/cervical-cancer/treatments/surgical-procedures-hysterectomy