Gestational trophoblastic disease
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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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