Referee report. For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 2 approved with reservations, 1 not approved]

Gestational Trophoblastic Disease, Placenta Diseases, Trophoblastic Tumor, Placental Site, pathology. ALL Metrics - Views Downloads How to cite this article Nesrine S, Bettaieb H, Mbarki W et al. Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.12688/f1000research.75075.2) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Case Report Revised Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved] Souayeh Nesrine https://orcid.org/0000-0001-7049-8076 1, Hajer Bettaieb1, Wael Mbarki1, [...] Ben Brahim Ehsen2, Helal Imen2, Ben Nasr Mehdi1, Oueslati Hedhili1, Hsayaoui Najeh1, Chaouki Mbarki https://orcid.org/0000-0001-7274-3733 1Souayeh Nesrine https://orcid.org/0000-0001-7049-8076 1, Hajer Bettaieb1, [...] Wael Mbarki1, Ben Brahim Ehsen2, Helal Imen2, Ben Nasr Mehdi1, Oueslati Hedhili1, Hsayaoui Najeh1, Chaouki Mbarki https://orcid.org/0000-0001-7274-3733 1 PUBLISHED 27 Oct 2023 Author details Author details 1 Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia 2 Department of Pathology, Habib Thameur Hospital, Faculty of Medicine of Tunis, Hbib Thameur Hospital, El Manar, Tunisia 2 Department of Pathology, Habib Thameur Hospital, Faculty of Medicine of Tunis, Hbib Thameur Hospital, El Manar, Tunisia Souayeh Nesrine Roles: Conceptualization, Writing – Original Draft Preparation Roles: Conceptualization, Writing – Original Draft Preparation Hajer Bettaieb Roles: Data Curation, Methodology, Resources Roles: Data Curation, Methodology, Resources Wael Mbarki Roles: Resources, Software Roles: Resources, Software Ben Brahim Ehsen Roles: Investigation, Methodology Roles: Investigation, Methodology Helal Imen Roles: Investigation, Methodology Roles: Investigation, Methodology Ben Nasr Mehdi Roles: Writing – Review & Editing Roles: Writing – Review & Editing Oueslati Hedhili Roles: Validation Roles: Validation Hsayaoui Najeh Roles: Formal Analysis, Project Administration, Supervision Roles: Formal Analysis, Project Administration, Supervision Chaouki Mbarki Roles: Supervision, Validation Roles: Supervision, Validation OPEN PEER REVIEW REVIEWER STATUS This article is included in the Oncology gateway. We report an uncommon clinical presentation of a placental site trophoblastic tumor. The patient presented initially with abdominal pain with, fever, bleeding and pelvic mass on ultrasonography leading to the wrong diagnosis of a pelvic abscess. Dilation and curettage were performed and pathological examination confirmed the diagnosis. of placental site trophoblastic tumor. Therefore, she underwent abdominal hysterectomy. Four years after surgery, the patient is still disease free. Gestational trophoblastic diseases should be considered in every patient presenting abnormal uterine bleeding after delivery or pregnancy loss despite the associated symptoms being very unusual. Gestational Trophoblastic Disease, Placenta Diseases, Trophoblastic Tumor, Placental Site, pathology. Corresponding Author(s) Chaouki Mbarki ([email protected]) Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2023 Nesrine S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Nesrine S, Bettaieb H, Mbarki W et al. Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.12688/f1000research.75075.2) First published: 01 Feb 2022, 11:129 (https://doi.org/10.12688/f1000research.75075.1) Latest published: 21 Oct 2024, 11:129 (https://doi.org/10.12688/f1000research.75075.3) This version of our article incorporates additional information as requested by one of our peer reviewers, particularly concerning the results of the CT scan performed prior to the abdominal hysterectomy, which revealed no secondary localization. This version of our article incorporates additional information as requested by one of our peer reviewers, particularly concerning the results of the CT scan performed prior to the abdominal hysterectomy, which revealed no secondary localization. See the authors' detailed response to the review by Guglielmo Stabile See the authors' detailed response to the review by Seetu Palo See the authors' detailed response to the review by Antonio Braga There is a newer version of this article available. of this article available. Placental site trophoblastic tumor (PSTT) is a rare tumor, representing 1% of gestational trophoblastic diseases.1,2 It mainly affects women of childbearing age after delivery or pregnancy loss.1–3 In this paper, we report a case of placental site trophoblastic tumor diagnosed by an array of pelvic abscess associated with bleeding occurring two months after delivery. The evolution, after surgical treatment by hysterectomy, was favorable. We report the case of an unemployed 32-year-old Arabic woman, gravida 1 and para 1, without medical history, gave birth naturally and without complications to a full-term healthy newborn. Two months after her delivery, she consulted our department with persisting metrorrhagia associated with fever of 39°C. The patient’s examination revealed that the bleeding has been noted since the delivery day and it had increased two days earlier. A physical examination revealed a fever of 39.5°C and abdominal tenderness. The blood pressure was 110/70 mm Hg and the heart rate was 82 beats/mn. Furthermore, there was no specific digestive or urinary symptom. Per speculum examination, the cervix was enlarged with purulent vaginal discharge. On digital pelvic examination, the uterus was increased in size accessed at 12 week gestation and its mobilization was painful. Blood tests showed an inflammatory syndrome with a C-reactive protein at 200 mg/l [≤ 6mg/l] and white blood cells at 17000/mm3 [4000-10000/mm3]. The beta-human chorionic gonadotropin (β-HCG) rate was positive at 674 U/l [< 5U/l]. The transvaginal sonography showed a large sized uterus containing an echogenic heterogeneous endometrial mass, vascularized on Doppler examination. This process seemed to invade the myometrium in part. In addition, ultrasound showed an average effusion in the Douglas' pouch (Figure 1) with a probable left adnexal abscess. Laparoscopic adnexal drainage and endometrial curettage were performed. The infectious episode resolved promptly with antibiotics; gentamicin 160 mg per day for 5 days metronidazole 500 mg three times a day for 15 days and cefotaxim 1g three times a day for 15 days. Pathological examination of the endometrial curettage specimen reported a proliferation of large tumor cell with eosinophilic cytoplasm and nuclear atypia, infiltrating the myometrium. These cells were positive for pro inflammatory cytokine (IL6) in the immunohistochemistry studies and the final diagnosis was a placental site trophoblastic tumor. A thoracoabdominopelvic CT scan was performed, and it did not reveal any secondary locations. A laparotomic hysterectomy with preservation of ovaries was performed. On gross examination there was a mass of 6 cm localized to the myometrium of bluish appearance with areas of hemorrhage and necrosis. The tumors had ill-defined borders and invaded into the myometrium (Figure 2). Pathological examination was similar to that described in the curettage specimen, showing a proliferation of monomorphic intermediate trophoblasts (Figure 3A). The tumor cells demonstrated nuclear atypia, eosinophilic cytoplasm (Figure 3D) and myometrial invasion (Figure 3B,C). Extensive necrosis, hemorrhage and vascular invasion are observed (Figure 3E). The final pathology report confirmed the diagnosis of PSTT infiltrating the myometrium. The postoperative course was favorable. The patient had a regular follow-up every month for the first year combining a clinical examination and a serum level of β-HCG. She had a clinical check-up and pelvic ultrasound every year for two years, no sign of recurrence was noted. Four years after surgery, the patient is still disease free. In 1895, Marchand first described PSTT and named it atypical chorioepithelioma.4 In 1981, Scully and Young described the morphological details and recognized it as a neoplastic process, and named it PSTT.5 PSTTs are a rare subtype of gestational trophoblastic disease, accounting for less than 1% of all cases.1,2,6 It mainly affects women of childbearing age and it is seen in patients between 19-62 years, with an average age of 30 years.1–3,6,7 PSTT can occur after a normal pregnancy, abortion, term delivery, ectopic pregnancy or molar pregnancy.1–3,6–8 Here we reported a case of PSTT occurring after a normal pregnancy. This pathology may occur months to years after pregnancy with the average interval between the antecedent pregnancy and diagnosis being 16 to 18 months.1–3,6,9 Diagnosis of PSTT can be difficult due to the nonspecific clinical signs. Abnormal uterine bleeding is the most common presenting feature.1–3,6–9 Metrorrhagia can also be associated with amenorrhea.1,8 The peculiarity of our case lies in the fact that the tumor was manifested by an array of pelvic abscess associated with bleeding; such clinical presentation was rare in literature.8 On digital pelvic examination, the uterus can be enlarged or normal sized.2,8 A wide range of other rare symptoms have also been reported, including galactorrhea, virilization, nephrotic syndrome, and polycythemia.2,8 PSTT can also be revealed by metastasis.2,7 The serum levels of β-hCG are usually in the range of 1000-2000 mIU/mL.1–3,6,9 The origin of PSTT is the intermediate trophoblast cells which secrete little beta HCG and a lot of placental lactogenic hormone.6,9 On gross examination, the tumors are located primarily in the endomyometrium, presenting as polypoid or nodular masses, with a variable diameter up to 10 cm.1,6 The sectioned surfaces of the tumors are solid, often fleshy, and usually yellow with necrosis, and hemorrhage.1,2,6 The tumor may extend into the cervix or infiltrate the serous, the adnexa or the round ligaments.2 In our case, the tumor invaded the myometrium without reaching the serous. The diagnosis of PSTT is based on pathological examination. On microscopic examination, we typically find a proliferation of intermediate trophoblastic cells without chorionic villi, which infiltrate muscle fibers.2 Vascular invasion, necrosis and hemorrhage are also often observed.2 The tumor is composed of a relatively monotonous population of polygonal cells with nuclear atypia and moderately abundant cytoplasm that can be amphophilic, eosinophilic or clear.1,2 The distinctive pattern of vascular invasion and deposition of fibrinoid material are the key diagnostic features.1–3 Usually, PSTTs have an unpredictable malignant potential and between 10 and 20% of patients have metastatic disease at the time of presentation.1,2,7,10 Metastasis site include peritoneum, vagina, lung, liver and brain. Hysterectomy without bilateral oophorectomy is the gold standard in PSTT management.2,10 In fact, this entity is particularly less responding to chemotherapy than hydatiforme mole, invasive mole and choriocarcinoma.2,10 When there is extension beyond the uterus, surgical treatment should be associated to chemotherapy.2,10 Nowadays we have, besides FIGO anatomical staging system as prognostic factor for PSTT surviving, the interval of last pregnancy and the initiating of treatment of 48 months.2,7,10,11 After surgical treatment, patients should be followed up during years to optimize the chance of detecting a relapse or metastasis.7,10‐12 This case report is interesting since it’s the first reporting PSTT simulating a pelvic abscess. However, PTTT are rare which prevents researchers from realizing large scale studies in order to develop valid management protocols. Although PSTTs are extremely rare worldwide, the diagnosis should be considered during the post-partum and post-abortion periods if there is persistent metrorrhagia. After surgical treatment, the follow up is needed to be accurate, to help recognize a relapse or metastasis. All data underlying the results are available as part of the article and no additional source data are required. Written informed consent for publication of clinical details and clinical images was obtained from the patient. - 1. Bouchet-Mishellany F, Ledoux-Pilon A, Darcha C, et al.: Tumeurs trophoblastiques gestationnelles: a propos d’un cas de tumeur trophoblastique du site placentaire et d’un cas de tumeur trophoblastique epithelioide. Ann. Pathol. 2004; 24: 167–171. Publisher Full Text - 2. Devouassoux-Shisheboran M, Allias F, Mathevet P, et al.: Gynecopathology: Pathologie gynecologique. Cas no 2: tumeur trophoblastique du site d’implantation placentaire. Ann. Pathol. 2012; 32: 189–193. PubMed Abstract | Publisher Full Text - 3. Baergen RN, Rutgers JL, Young RH, et al.: Placental site trophoblastic tumor: a study of 55 cases and review of the literature emphasizing factors of prognostic significance. Gynecol. Oncol. 2006; 100: 511–520. PubMed Abstract | Publisher Full Text - 4. Marchand F: Uber die sogenannten “decidualen” geschwulste im Anschlus an normale Gebart, Abort, Blasenmole und Extrauterine Schwangerschaft. Monatsschr Geburtshilfe Gynaekol 1985; 1: 419–438. - 5. Scully RE, Young RH: Trophoblastic pseudotumor. A reappraisal. Am. J. Surg. Pathol. 1981; 5: 75–76. PubMed Abstract | Publisher Full Text - 6. Mardi K, Kaushal V: Placental site trophoblastic tumor - a challenging, rare entity. Taiwan. J. Obstet. Gynecol. 2010; 49: 533–535. PubMed Abstract | Publisher Full Text - 7. Colecchi C, Partemi S, Minelli N, et al.: Placental site trophoblastic tumor with lung metastases as cause of death in a young patient: A case report. Placenta 2011; 32: 1060–1063. PubMed Abstract | Publisher Full Text - 8. Vuong PN, Guillet JL, Houissa-Vuong S, et al.: Pathologie des tumeurs trophoblastiques gestationnelles. Gynecol. Obstet. Fertil. 2000; 28: 913–926. Publisher Full Text - 9. Yalinkaya A, Ali Irfan Guzel AI, Kangal K, et al.: Two cases of placental site trophoblastic tumor. Taiwan. J. Obstet. Gynecol. 2011; 50: 372–374. PubMed Abstract | Publisher Full Text - 10. Sergent F, Verspyck E, Lemoine JP, et al.: Place de la chirurgie dans la prise en charge des tumeurs trophoblastiques gestationnelles. Gynecol. Obstet. Fertil. 2006; 34: 233–238. Publisher Full Text - 11. Rauw L, Delbecque K, Goffin F, et al.: Atypical recurrence of a placental site trophoblastic tumor four years after hysterectomy for benign condition: Case report and review of literature. Gynecol. Oncol. Rep. 2013; 6: 36–38. PubMed Abstract | Publisher Full Text - 12. Froeling FEM, Ramaswami R, Papanastasopoulos P, et al.: Intensified therapies improve survival and identification of novel prognostic factors for placental-site and epithelioid trophoblastic tumours.Br. J. Cancer.2019 Mar;120(6): 587–594. Epub 2019 Feb 22.PubMed Abstract | Publisher Full Text | Free Full Text Author details Author details 1 Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia 2 Department of Pathology, Habib Thameur Hospital, Faculty of Medicine of Tunis, Hbib Thameur Hospital, El Manar, Tunisia 2 Department of Pathology, Habib Thameur Hospital, Faculty of Medicine of Tunis, Hbib Thameur Hospital, El Manar, Tunisia Souayeh Nesrine Roles: Conceptualization, Writing – Original Draft Preparation Roles: Conceptualization, Writing – Original Draft Preparation Hajer Bettaieb Roles: Data Curation, Methodology, Resources Roles: Data Curation, Methodology, Resources Wael Mbarki Roles: Resources, Software Roles: Resources, Software Ben Brahim Ehsen Roles: Investigation, Methodology Roles: Investigation, Methodology Helal Imen Roles: Investigation, Methodology Roles: Investigation, Methodology Ben Nasr Mehdi Roles: Writing – Review & Editing Roles: Writing – Review & Editing Oueslati Hedhili Roles: Validation Roles: Validation Hsayaoui Najeh Roles: Formal Analysis, Project Administration, Supervision Roles: Formal Analysis, Project Administration, Supervision Chaouki Mbarki Roles: Supervision, Validation Roles: Supervision, Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) Copyright © 2023 Nesrine S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics | Views | Downloads | | |---|---|---| | F1000Research | - | - | | PubMed Central Data from PMC are received and updated monthly. | - | - | Citations CITE how to cite this article Nesrine S, Bettaieb H, Mbarki W et al. Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.12688/f1000research.75075.2) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 27 Oct 2023 Revised Views 0 How to cite this report: Palo S. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.157888.r321955) The direct URL for this report is: https://f1000research.com/articles/11-129/v2#referee-response-321955 https://f1000research.com/articles/11-129/v2#referee-response-321955 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 25 Sep 2024 Seetu Palo, All India Institute of Medical Sciences, Hyderabad, India Approved with Reservations VIEWS 0 This is a well-documented case report on a rare condition, providing valuable insights into the diagnosis and management of placental site trophoblastic tumor (PSTT). Strengthening the discussion around the unique presentation and refinement in structure and depth of discussion, particularly ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close This is a well-documented case report on a rare condition, providing valuable insights into the diagnosis and management of placental site trophoblastic tumor (PSTT). Strengthening the discussion around the unique presentation and refinement in structure and depth of discussion, particularly around clinical implications and differential diagnosis, would improve the manuscript. The description of imaging findings is well-executed, and the figures provide useful visual aids. However, there are some issues with figure referencing and clarity. Figure 1 is briefly mentioned in the text, but the explanation could be expanded to better connect the ultrasound findings to the case narrative. Similarly, the histopathological micro-photographs, which forms the basis of diagnosis, need to be of better resolution with appropriate annotations for better understanding of the readers. The authors should discuss about microscopic differential diagnoses, such as, exaggerated placental site response, epithelioid trophoblastic tumor and gestational choriocarcinoma, and state how were these differentials excluded in this particular case. The description of the surgical management (hysterectomy) is clear, and the follow-up section is well done, providing a clear timeline of surveillance for recurrence, which is crucial in managing PSTT. However, additional information regarding β-HCG levels over time would further strengthen the post-treatment monitoring discussion. A brief note on emerging treatment options or potential prognostic factors could further enrich the discussion. The description of imaging findings is well-executed, and the figures provide useful visual aids. However, there are some issues with figure referencing and clarity. Figure 1 is briefly mentioned in the text, but the explanation could be expanded to better connect the ultrasound findings to the case narrative. Similarly, the histopathological micro-photographs, which forms the basis of diagnosis, need to be of better resolution with appropriate annotations for better understanding of the readers. The authors should discuss about microscopic differential diagnoses, such as, exaggerated placental site response, epithelioid trophoblastic tumor and gestational choriocarcinoma, and state how were these differentials excluded in this particular case. The description of the surgical management (hysterectomy) is clear, and the follow-up section is well done, providing a clear timeline of surveillance for recurrence, which is crucial in managing PSTT. However, additional information regarding β-HCG levels over time would further strengthen the post-treatment monitoring discussion. A brief note on emerging treatment options or potential prognostic factors could further enrich the discussion. - Is the background of the case’s history and progression described in sufficient detail? Yes - Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly - Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes - Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pathology CITE HOW TO CITE THIS REPORT Palo S. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.157888.r321955) The direct URL for this report is: https://f1000research.com/articles/11-129/v2#referee-response-321955 https://f1000research.com/articles/11-129/v2#referee-response-321955 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 21 Oct 2024chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia21 Oct 2024Author ResponseDear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript ... Continue reading Dear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again.Dear Reviewer,Competing Interests: None Close Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again. COMMENTS ON THIS REPORT - Author Response 21 Oct 2024chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia21 Oct 2024Author ResponseDear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript ... Continue reading Dear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again.Dear Reviewer,Competing Interests: None Close Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again. Views 0 How to cite this report: Stabile G. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.157888.r321960) The direct URL for this report is: https://f1000research.com/articles/11-129/v2#referee-response-321960 https://f1000research.com/articles/11-129/v2#referee-response-321960 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 24 Sep 2024 Approved with Reservations VIEWS 0 Dear Authors and Editor, thank you to allow me tor review this interesting case report. In my opinion the subject is very interesting and report is useful for the diagnosis and management of such rare clinical event. In my ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close In my ... Continue reading Dear Authors and Editor, thank you to allow me tor review this interesting case report. In my opinion the subject is very interesting and report is useful for the diagnosis and management of such rare clinical event. In my opinion an important point to be discussed is the possibility to preserve the placenta for 24-48 hours after each birth, to perform histological examination even in the case in which the birth was physiological but particular symptoms appeared in the hours immediately after birth (also in this case, after an in-depth medical history, the bleeding was already abundant after birth. This procedure could led to a better and faster diagnosis of this as well as other even rarer placental pathologies [ref 1] . A few more histological tests would improve the outcomes in terms of survival and fertility sparing of the patients. In my opinion an important point to be discussed is the possibility to preserve the placenta for 24-48 hours after each birth, to perform histological examination even in the case in which the birth was physiological but particular symptoms appeared in the hours immediately after birth (also in this case, after an in-depth medical history, the bleeding was already abundant after birth. This procedure could led to a better and faster diagnosis of this as well as other even rarer placental pathologies [ref 1] . A few more histological tests would improve the outcomes in terms of survival and fertility sparing of the patients. - Is the background of the case’s history and progression described in sufficient detail? Yes - Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes - Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No - Is the case presented with sufficient detail to be useful for other practitioners? Yes

1. Stabile G, Gentile RM, Carlucci S, Stampalija T, et al.: Maternal and fetal outcomes of intraplacental choriocarcinoma complicated by fetomaternal hemorrhage: a systematic review.J Matern Fetal Neonatal Med. 2023; 36 (2): 2285238 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed. Reviewer Expertise: Expert in Placental Pathology CITE HOW TO CITE THIS REPORT Stabile G. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.157888.r321960) The direct URL for this report is: https://f1000research.com/articles/11-129/v2#referee-response-321960 https://f1000research.com/articles/11-129/v2#referee-response-321960 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 17 Oct 2024chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia17 Oct 2024Author ResponseDear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript ... Continue reading Dear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again.Dear Reviewer,Competing Interests: No competing interests were disclosed. Close Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again. COMMENTS ON THIS REPORT - Author Response 17 Oct 2024chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia17 Oct 2024Author ResponseDear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript ... Continue reading Dear Reviewer, Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again.Dear Reviewer,Competing Interests: No competing interests were disclosed. Close Thank you for reviewing our article. I truly appreciate all your remarks and comments. I have made the necessary revisions, which you can find in the revised manuscript (version 3). I hope the updated version meets your approval. Thank you once again. Version 1 VERSION 1 PUBLISHED 01 Feb 2022 Views 0 How to cite this report: Aniţei MG. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.78892.r159682) The direct URL for this report is: https://f1000research.com/articles/11-129/v1#referee-response-159682 https://f1000research.com/articles/11-129/v1#referee-response-159682 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 19 Jan 2023 Not Approved VIEWS 0 I was pleased to review the article Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess. The methodology used by the authors is appropriate for the purpose of the study and conclusions are narrowly linked to ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close The methodology used by the authors is appropriate for the purpose of the study and conclusions are narrowly linked to ... Continue reading I was pleased to review the article Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess. The methodology used by the authors is appropriate for the purpose of the study and conclusions are narrowly linked to available evidence. The title expresses clearly the content of the manuscript and highlights the importance of the study. As the authors note in Strengths and limitations, this case report is interesting since it is the first reporting of PSTT simulating a pelvic abscess. There was rapid evolution of tumor development, only 2 months after natural birth, apparently without a risk factor from her medical history. There are interesting images intraoperative and microscopy The article respects the presentation algorithm that is required for a case report type article, but there is a number of medical details are missing, such as no detailed investigations (CT-scan, for example) to exclude metastases, both at the time of diagnosis and follow-up. In the same direction, to improve the methodology of this study, the introduction section must be improved. It is too short, and I suggest that some information regarding diagnosis and prognosis of PSTT should be included. Likewise, Immunohistochemistry data and the FIGO score are missing from the anatomopathological presentation, this information would increase the value of the article. Likewise, to be more convincing, the authors could image the patient at a distance through an CT-scan exam to confirm, through this high-performance investigation, the absence of local or distant disease. These tests would help to exclude metastases, both at the time of diagnosis and follow-up, especially as the anatomical-pathological examination shows a vascular invasion. The conclusion of the article could be strengthened. Although PSTTs are extremely rare worldwide, the diagnosis should be considered during the post-partum and postabortion periods if there is persistent metrorrhagia - this means that, in front of a patient with metrorrhagia and febrile syndrome that appeared early after delivery, this differential diagnosis (PSTT) must also be taken into account. Other points: 1. It doesn't seem representative to me that pathology should be a Keywords 2. immunohistochemistry data and the FIGO score are missing from the anatomopathological presentation 3. Usually, 'PSTTs are benign tumors' – I am not agree with this affirmation 4. In figure 3- the microscopy details must be specified - is it an image of HE? , how many times is it amplified ( which objective was used?) . As the area of interest is identified in image D, I recommend that the same thing be done for the other images (Figure 3- A, B, C, E) The methodology used by the authors is appropriate for the purpose of the study and conclusions are narrowly linked to available evidence. The title expresses clearly the content of the manuscript and highlights the importance of the study. As the authors note in Strengths and limitations, this case report is interesting since it is the first reporting of PSTT simulating a pelvic abscess. There was rapid evolution of tumor development, only 2 months after natural birth, apparently without a risk factor from her medical history. There are interesting images intraoperative and microscopy The article respects the presentation algorithm that is required for a case report type article, but there is a number of medical details are missing, such as no detailed investigations (CT-scan, for example) to exclude metastases, both at the time of diagnosis and follow-up. In the same direction, to improve the methodology of this study, the introduction section must be improved. It is too short, and I suggest that some information regarding diagnosis and prognosis of PSTT should be included. Likewise, Immunohistochemistry data and the FIGO score are missing from the anatomopathological presentation, this information would increase the value of the article. Likewise, to be more convincing, the authors could image the patient at a distance through an CT-scan exam to confirm, through this high-performance investigation, the absence of local or distant disease. These tests would help to exclude metastases, both at the time of diagnosis and follow-up, especially as the anatomical-pathological examination shows a vascular invasion. The conclusion of the article could be strengthened. Although PSTTs are extremely rare worldwide, the diagnosis should be considered during the post-partum and postabortion periods if there is persistent metrorrhagia - this means that, in front of a patient with metrorrhagia and febrile syndrome that appeared early after delivery, this differential diagnosis (PSTT) must also be taken into account. Other points: 1. It doesn't seem representative to me that pathology should be a Keywords 2. immunohistochemistry data and the FIGO score are missing from the anatomopathological presentation 3. Usually, 'PSTTs are benign tumors' – I am not agree with this affirmation 4. In figure 3- the microscopy details must be specified - is it an image of HE? , how many times is it amplified ( which objective was used?) . As the area of interest is identified in image D, I recommend that the same thing be done for the other images (Figure 3- A, B, C, E) - Is the background of the case’s history and progression described in sufficient detail? Partly - Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly - Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes - Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: oncological gynecology CITE HOW TO CITE THIS REPORT Aniţei MG. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.78892.r159682) The direct URL for this report is: https://f1000research.com/articles/11-129/v1#referee-response-159682 https://f1000research.com/articles/11-129/v1#referee-response-159682 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Views 0 How to cite this report: Braga A. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.78892.r125758) The direct URL for this report is: https://f1000research.com/articles/11-129/v1#referee-response-125758 https://f1000research.com/articles/11-129/v1#referee-response-125758 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 07 Mar 2022 Approved with Reservations VIEWS 0 Dear Authors and Editors, I would like to thank you for the opportunity to review the paper entitled: “Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess”, submitted to the F1000. Similarly, I would ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close I would like to thank you for the opportunity to review the paper entitled: “Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess”, submitted to the F1000. Similarly, I would ... Continue reading Dear Authors and Editors, I would like to thank you for the opportunity to review the paper entitled: “Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess”, submitted to the F1000. Similarly, I would like to congratulate the authors for their interest in the topic. In this case report, the authors presented a description of a PSTT presenting as abdominal abscess, reviewing the literature of this subject. I would like to highlight some aspects that deserve attention. I would like to thank you for the opportunity to review the paper entitled: “Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess”, submitted to the F1000. Similarly, I would like to congratulate the authors for their interest in the topic. In this case report, the authors presented a description of a PSTT presenting as abdominal abscess, reviewing the literature of this subject. I would like to highlight some aspects that deserve attention. - The authors must describe in the case report the screening for metastatic disease, to justify the decision for TAH. - PSTT is always cancer, not a benign tumor as described. - Nowadays we have, besides FIGO anatomical staging system as prognostic factor for PSTT surviving, the interval of last pregnancy and the initiating of treatment of 48 months.1 - In the section 'Strengths and Limitations' there is a PTTT that should be corrected. - Is the background of the case’s history and progression described in sufficient detail? Partly - Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly - Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes - Is the case presented with sufficient detail to be useful for other practitioners? Yes

1. Froeling FEM, Ramaswami R, Papanastasopoulos P, Kaur B, et al.: Intensified therapies improve survival and identification of novel prognostic factors for placental-site and epithelioid trophoblastic tumours.Br J Cancer. 120 (6): 587-594 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed. Reviewer Expertise: Gestational trophoblastic disease CITE HOW TO CITE THIS REPORT Braga A. Reviewer Report For: Case Report: Placental site trophoblastic tumor revealed by a clinical pelvic abscess [version 2; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2023, 11:129 (https://doi.org/10.5256/f1000research.78892.r125758) The direct URL for this report is: https://f1000research.com/articles/11-129/v1#referee-response-125758 https://f1000research.com/articles/11-129/v1#referee-response-125758 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 06 Nov 2023chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia06 Nov 2023Author ResponseDear reviewer, Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, ... Continue reading Dear reviewer, Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, the patient had undergone a total abdominal hysterectomy after a thoracoabdominopelvic CT scan revealed no metastatic lesions. We have also addressed all the other issues as per your request, which you can verify in the revised version. We would greatly appreciate it if you could approve this paper now that we have made the necessary amendments. Thank you for your assistance.Dear reviewer,Competing Interests: No competing interests were disclosed. Close Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, the patient had undergone a total abdominal hysterectomy after a thoracoabdominopelvic CT scan revealed no metastatic lesions. We have also addressed all the other issues as per your request, which you can verify in the revised version. We would greatly appreciate it if you could approve this paper now that we have made the necessary amendments. Thank you for your assistance. COMMENTS ON THIS REPORT - Author Response 06 Nov 2023chaouki mbarki, Department of Obstetrics and Gynecology, Ben Arous Hospital, Faculty of Medicine, Ben Arous Hospital, El Manar, Tunisia06 Nov 2023Author ResponseDear reviewer, Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, ... Continue reading Dear reviewer, Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, the patient had undergone a total abdominal hysterectomy after a thoracoabdominopelvic CT scan revealed no metastatic lesions. We have also addressed all the other issues as per your request, which you can verify in the revised version. We would greatly appreciate it if you could approve this paper now that we have made the necessary amendments. Thank you for your assistance.Dear reviewer,Competing Interests: No competing interests were disclosed. Close Thank you for taking the time to review our article and for your valuable feedback. I will address your comments as follows: Regarding your first comment, the patient had undergone a total abdominal hysterectomy after a thoracoabdominopelvic CT scan revealed no metastatic lesions. We have also addressed all the other issues as per your request, which you can verify in the revised version. We would greatly appreciate it if you could approve this paper now that we have made the necessary amendments. Thank you for your assistance. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | |||| |---|---|---|---|---| | 1 | 2 | 3 | 4 | | | Version 3 (revision) 21 Oct 24 | read | read | || | Version 2 (revision) 27 Oct 23 | read | read | || | Version 1 01 Feb 22 | read | read | - Seetu Palo, All India Institute of Medical Sciences, Hyderabad, India Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' - Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. - You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. - You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). - You work at the same institute as any of the authors. - You hope/expect to benefit (e.g. favour or employment) as a result of your submission. - You are an Editor for the journal in which the article is published. 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