Introduction

•Placental site nodule ( is a benign proliferation of intermediate trophoblast
cell in endometrium or endocervix after intrauterine gestation
Atypical nodules have the potential to progress to Placental site trophoblastic
tumour ( or epithelioid trophoblastic tumour ( PSN, APSN and ETT
are described as a spectrum with progressively increasing malignant potential
• It needs follow up as it is a rare diagnosis with limited clinical experience and
management guidance

 

Objective and design
• In our unit, 3 cases of atypical placental site nodules were histologically diagnosed
in 12 months
• Each had a different presentation, follow up plan and management although
similar histopathological results, leading to literature review

Case 1
• 41 year old attended with irregular periods
• Miscarriage at 16 weeks 6 moths before symptoms
• Hysteroscopic evaluation showed retained products of conception ( like
product at fundus
• Reported by histopathology as borderline APSN with mild to moderate atypia
with Ki 67 of 5
• Serial HCG follow up was agreed as management and have been in normal
range

Case 2
• 31 year old presented with ongoing bleeding for 2 months following
mid trimester miscarriage
• Previous 1 Caesarean section
• Hysteroscopic removal of RPOC was done
• Reported as APSN with high proliferative index with Ki 67 of 30
• Hysterectomy was recommended, however she declined and has successfully
carried a pregnancy to term without complications

Case 3
• 18 year old on medroxyprogesterone injections and amenorrhoeic, presented with
pelvic pain
• Surgical termination of pregnancy in past
• During evaluation, fluid filled area at fundus was recognised at fundus which was
biopsied under hysteroscopic guidance
• Histopatholgy report was APSN with low proliferative index and Ki 67 of 10 and
hence follow up with HCG was commenced and have all been normal till date

Discussion
Presentation
• Reproductive age women may present with menorrhagia, irregular
cycles, dysmenorrhoea, recurrent miscarriage, subfertility, post coital
bleeding, or abnormal cervical smear 1
• Surgical procedures on the uterus are believed to interfere with normal
endometrial shedding and can lead to abnormal involution of placental
tissue

Diagnosis
• Hysteroscopic appearance is of yellow or tan nodule on endometrium
• Microscopically it is described as well defined hyalinised eosinophilic
nodules with intermediate trophoblast
• Ki 67 can be 5 10 in atypical placental site nodules 5 in PSN)

Follow up and prognosis
• HCG
• CT and/or MRI to rule out metastasis
• Under the care of a regional Trophoblastic Diseases Centre (within the
UK)
• 14% of APSN are shown to progress to ETT or PSTT 2

Conclusion
• With increasing evidence of APSN progressing to ETT/PSTT regular
follow up is mandatory
• Lack of markers of progressive change into malignancy is a limiting
factor
• Individualised care based on age, fertility, patient choice and pathology
and immunohistochemistry should be practiced

References

1. Young et al, Nov 1990, AJSP,
doi : 10.1097/00000478 199011000 00002. PMID: 2240354.
2. Kaur et al, March 2015, IJGP,
doi : 10.1097/PGP.0000000000000128
3. Le ming et al Human Pathology, Volume 30, Issue 6, 1999, ISSN 0046 8177,
https://doi.org/10.1016/S0046 8177(99)90095 3