Tehran University Medical Journal

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Background: Gestational trophoblastic disease (GTD) is a heterogenous group of neoplastic lesions that is derived from placental trophoblastic epithelium. According to World Health Organization (WHO) classification they include: Hydatidiform mole (complete and partial), invasive mole, choriocarcinoma and placental site trophoblastic tumor. Hydatidiform mole is the most common and the diagnosis is achieved by pre-evacuation ultrasonographic evaluation, laboratory tests and finally histological assessment as gold standard. Since these disorders show varying potential for local invasion and metastasis, the accurate diagnosis, follow up and recommendations given to patients may differ.
Methods: Consecutive cases with diagnosis of GTD from archive of pathology department of women (Mirza Kochak Khan) hospital were reviewed in whom results of clinical presentation and pre-evacuation ultrasound examination were documented. There were overall 220 cases for which the following clinical features were determined: gravidity, parity, history of previous abortion and gestational trophoblastic disease, the clinical symptoms such as vaginal bleeding and hypertension. Finally concordance between pre-evacuation ultrasonographic and histological diagnosis by kappa test is calculated.
Results: Out of 220 cases with clinically gestational trophoblastic disease diagnosis, 197 cases were confirmed by histological diagnosis. The concluding histological diagnosis includes: 98 cases of complete mole (CM), 84 partial mole (PM), 4 invasive mole and 11 cases of choriocarcinoma. Outside 98 cases with histological diagnosis CM only in 4 cases misdiagnosed by ultrasonoghraphy (4.1%) and high degree of concordance between ultrasonography and histological diagnosis is seen.
Conclusion: Ultrasonographic examination accompanied with clinical examination, beside histological assessment as gold standard have high efficacy in diagnosing  complete mole. This study did not show this finding for partial mole.

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cBackground: Choriocarcinoma is a highly malignant form of gestational trophoblastic disease. It is characterized by metastatic potential, rapid growth and deeply invasion into blood vessel and then widespread dissemination metastasis. However, the most common sites of metastatic choriocarcinoma are lung, vagina, liver, and brain. But, metastatic choriocarcinomas rarely is extended to gastrointestinal system. It is im-portant to keep in mind that despite extensive metastasis, choriocarcinoma is very curable disease. Due to high responsibility of this disease, early diagnosis of choriocarcinoma and treatment with chemotherapy can prevent mortality and morbidity of these patients. In this case report, we present a rare case of metastatic choriocarcinoma in the small bowel after normal term pregnancy. Case Presentation: A 34-years-old woman G4, P4, L4 presented with abnormal postpar-tum vaginal bleeding (45 days) and unresponsive to usual medical and surgical therapy (oxytocine, metergene, antibiotic, and double curettage). The patient was admitted in the Ghaem Hospital, Mashhad University of Medical Sciences in April 2013. She suf-fered from rectal hemorrhage and severe weakness. Because of unsuitable condition (shock), laparotomy was performed and small bowel involvement was observed. Seg-mental resection of small bowel detected metastatic choriocarcinoma of the lesion. We couldn’t rescue our patient due to unresponsive to combination chemotherapy (actino-mycine, methotrexate, cyclophosfamide, vincrystine, etopuside). Conclusion: In abnormal postpartum hemorrhage, we should consider the possibility of choriocarcinoma. Although, it is important to note rare manifestations of metastatic choriocarcinoma of small bowel in massive gastrointestinal hemorrhage.

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Background: Standard treatment of Gestational Trophoblastic Disease (GTD) is chemotherapy. Single-agent chemotherapy regime including Methotrexate (MTX) or Actinomycin. Single-agent is widely used in treatment of persistent trophoblastic disease. We reported an uncommon toxicity of low-dose single-agent methotrexate in a patient. Case Presentation: A 20-year-old woman, primary gravid after two months missed period and spotting with diagnosis of incomplete abortion with uterine size equivalent of ten weeks pregnancy (8-10 cm) underwent evacuation curettage. In serial follow-up, based on rise of beta-hCG titer and absence of metastatic disease, it was categorized as low-risk persistent trophoblastic disease. She was referred to gynecology oncology center of Ghaem Hospital, Mashhad University of Medical Sciences in May 2014. Because of rise of beta-hCG titer, after complete metastatic work-up and lack of disease in other sites, persistent disease was diagnosed and candidate for chemotherapy (single agent low-dose). The patient received first course of therapy with MTX (50 mg/m², intra muscular). Unfortunately, after two days of treatment she developed uncommon severe toxicity, fever, severe nausea and vomiting, tachycardia, and generalized weakness. Also, we found hematologic abnormality (WBC: -14000-15000 µI, platelet- 540 µI and sever neutropenia), and abnormal rising in liver function test (SGOT, SGPT) (three to four times) and renal function test (BUN and Creatinine) (two times). In addition, she had disseminated erosive lesion in all of body especially in face. Due to the fatal side effects of chemotherapy, she was admitted to intensive care unit (ICU). Fortunately, after two to three weeks, she was improved by conservative management. After few weeks beta-hCG titer was in normal limit. However she had normal serial beta-hCG in one year of follow-up. Conclusion: It is important to emphasis unpredictable side effects of chemotherapy with low-dose methotrexate.

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Results: 74 patients were monitored, 83.78% of them had uncomplicated pregnancy and labor, 4.05% had the abortion, 4.05% had second molar pregnancy, 2.7% had pre-eclampsia, 5.40% had preterm labor. Moreover, stillbirth and malformation did not occur in this study even after chemotherapy treatment. There was not any significant correlation between age, BMI, parity, and chemotherapy duration with pregnancy outcomes. Conclusion: The outcomes of pregnancy after chemotherapy with actinomycin-D is similar to the general population who did not have chemotherapy. The abortion rate and repeated molar pregnancy were similar between population and sample too. Thus, the study shows that the cured patients with low-risk GTN have as much chance of having a normal pregnancy as normal women. In other words, treatment with actinomycin-D does not have any adverse effect in future pregnancies.

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