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Gestational Trophoblastic Disease. Definitions. Gestational Trophoblastic Neoplasia (GTN)  chorioadenoma destruens, metastasizing mole, choriocarcinoma. Non-metastatic gestational trophoblastic neoplasia: process is confined to the uterus

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definitions
Definitions
  • Gestational Trophoblastic Neoplasia (GTN)  chorioadenoma destruens, metastasizing mole, choriocarcinoma.
    • Non-metastatic gestational trophoblastic neoplasia: process is confined to the uterus
    • Metastatic gestational trophoblastic neoplasia: metastases are demonstrated in the lung/vagina and/or in brain, liver, kidney or elsewhere
  • Hydatidiform mole: Gestational Trophoblastic Disease (GTD).
classification
Classification
  • Hydatidiform mole
    • Complete mole
    • Partial mole
  • Invasive mole
  • Placental-site trophoblastic tumor
  • Choriocarcinoma
complete hydatidiform mole
Complete Hydatidiform Mole
  • Pathology
    • Identifiable embryonic/fetal tissue Θ
    • Chorionic villi: generalized hydatidiform swelling, diffuse trophoblastic hyperplasia
  • Chromosomes: 46XX karyotype, molar chromosomes  paternal origin
partial hydatidiform mole
Partial Hydatidiform Mole
  • Pathology:
    • Chorionic villi with focal hydatidiform swelling and cavitation
    • Villous scalloping
    • Focal trophoblastic hyperplasia
    • Prominent stromal trophoblastic inclusions
    • Identifiable embryonic or fetal tissue
  • Chromosomes: triploid karyotype (69 chromosomes)
clinical features
Clinical Features
  • Complete Hydatidiform Mole
    • Vaginal bleeding
    • Excessive uterine size
    • Toxemia
    • Hyperemesis gravidarum
    • Hyperthyroidism
    • Trophoblastic embolization
    • Theca lutein ovarian cyst
  • Partial Hydatidiform Mole: signs & symptoms of incomplete / missed abortion
diagnosis
Diagnosis
  • USG : vesicular sonographic pattern  “snowstorm” pattern
follow up
Follow-up
  • Human Chorionic Gonadotropin

Contraception

  • IUD  normal hCG level
  • First choice:
    • Hormonal contraception
    • Barrier methods
malignant gestational trophoblastic neoplasia
Malignant Gestational Trophoblastic Neoplasia
  • Nonmetastatic Disease
  • Metastatic Disease
nonmetastatic disease
Nonmetastatic Disease
  • Signs & symptoms:
    • Irregular vaginal bleeding
    • Theca lutein cysts
    • Uterine subinvolution or asymmetric enlargement
    • Persistently elevated serum hCG levels
  • Histology: anaplastic syncytiotrophoblast & cytotrophoblast w/o chorionic villous structure
placental site trophoblastic tumor
Placental-site Trophoblastic Tumor
  • Consist of: intermediate trophoblast & a few syncytial elements
  • Produce small amount of hCG & human placental lactogen
  • Tend to remain confined to the uterus
  • Metastasizing late
  • Insensitive to chemtotherapy
metastatic disease
Metastatic Disease

Sites of metastatic spread:

  • Pulmonary:
    • Signs: chest pain, cough, hemoptysis,d yspnea, asymptomatic lesion
    • Radiographic patterns: an alveolar or “snowstrom” pattern; discrete, rounded densities; pleural effusion; an embolic pattern caused by pulmonary arterial occlusion
metastatic disease1
Metastatic Disease

Sites of metastatic spread:

  • Vaginal: highly vascular, appear reddened or violaceous
  • Hepatic: epigastric or right upper quadrant pain  Glisson’s capsule; hepatic lesions: hemorrhagic & friable & may rupture  exsanguinating intraperitoneal bleeding
  • Central Nervous System: brain metastasis was preceded by pulmonary &/or vaginal involvement; acute focal neurologic deficits.
metastatic disease2
Metastatic Disease

Diagnostic evaluation:

  • Pretreatment evaluation:
    • A complete hystory & physical examination
    • Measurement of the serum hCG value
    • Hepatic, thyroid, & renal function tests
    • Determination of baseline peripheral MBC & platelet counts
metastatic disease3
Metastatic Disease

Diagnostic evaluation:

  • Metastatic work-up:
    • A chest radiograph
    • USG / CT scan of the abdomen & pelvis
    • Measurement of CSF hCG level
    • Angiography of abdominal & pelvic organs
figo staging
FIGO Staging
  • Stage I: Gestational trophoblastic tumors strictly confined to the uterine corpus
  • Stage II: Gestational trophoblastic tumors extending to the adnexa or to the vagina, but limited to the genital structures
  • Stage III: Gestational trophoblastic tumors extending to the lungs, w/ or w/o genital tract involvement
  • Stage IV: all other metastatic sites.
subsequent pregnancies
Subsequent pregnancies
  • Pregnancies after Hydatidiform Mole: patients with a complete molar pregnancy are at no increased risk of obstetric complications.
  • For any subsequent pregnancy, these things are recommended:
    • A pelvic USG during the 1st trimester
    • A thorough histologic review of the placenta or products of conception
    • An hCG measurement 6 weeks after completion of the pregnancy to exclude occult trophoblastic neoplasia
subsequent pregnancies1
Subsequent pregnancies

Pregnancies after Persistent GTN

  • Patients w/ GTN who are treated successfully w/ chemotherapy can expect normal reproduction.
  • Frequency of congenital melformations was not increased, although chemotherapeutic agents have teratogenic & mutagenic potential.
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