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Gestational Trophoblastic Disease

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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Gestational Trophoblastic Disease

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  1. Gestational Trophoblastic Disease

  2. 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).

  3. Classification • Hydatidiform mole • Complete mole • Partial mole • Invasive mole • Placental-site trophoblastic tumor • Choriocarcinoma

  4. Complete Hydatidiform Mole • Pathology • Identifiable embryonic/fetal tissue Θ • Chorionic villi: generalized hydatidiform swelling, diffuse trophoblastic hyperplasia • Chromosomes: 46XX karyotype, molar chromosomes  paternal origin

  5. 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)

  6. 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

  7. Diagnosis • USG : vesicular sonographic pattern  “snowstorm” pattern

  8. Follow-up • Human Chorionic Gonadotropin Contraception • IUD  normal hCG level • First choice: • Hormonal contraception • Barrier methods

  9. Malignant Gestational Trophoblastic Neoplasia • Nonmetastatic Disease • Metastatic Disease

  10. 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

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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

  16. 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.

  17. FIGO (WHO) Risk Factor Scoring w/ FIGO Staging

  18. Management of Gestational Trophoblastic Disease

  19. Figure 2: Management of Trophoblastic Neoplasia

  20. Figure 3: Management of Trophoblastic Neoplasia

  21. Management of Trophoblastic Disease

  22. 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

  23. 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.

  24. THANK YOU

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