Transcript 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
– 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
• Hydatidiform mole
– Complete mole
– Partial mole
• Invasive mole
• Placental-site trophoblastic tumor
• Choriocarcinoma
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
• 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
• 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
• USG : vesicular sonographic pattern 
“snowstorm” pattern
Follow-up
• Human Chorionic Gonadotropin
Contraception
• IUD  normal hCG level
• First choice:
– Hormonal contraception
– Barrier methods
Malignant Gestational Trophoblastic
Neoplasia
• Nonmetastatic Disease
• Metastatic 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
• 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
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 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 Disease
Diagnostic evaluation:
• Pretreatment evaluation:
1.
2.
3.
4.
A complete hystory & physical examination
Measurement of the serum hCG value
Hepatic, thyroid, & renal function tests
Determination of baseline peripheral MBC &
platelet counts
Metastatic Disease
Diagnostic evaluation:
• Metastatic work-up:
1.
2.
3.
4.
A chest radiograph
USG / CT scan of the abdomen & pelvis
Measurement of CSF hCG level
Angiography of abdominal & pelvic organs
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.
FIGO (WHO) Risk Factor Scoring w/ FIGO
Staging
0
1
2
Age
Antecedent
pregnancy
Interval months from
Index Pregnancy
Pretreatment hCG
Milli IU/MI
< 40
 40
Hydatidifor
m
Mole
Abortion
Term
<4
4–6
7 – 12
< 103
103-104
Largest tumor size
including uterus
3 – 4 cm
Site of metastases
including uterus
Spleen
kidney
Number of
metastases identified
Previous failed
chemotherapy
1–4
4
> 12
>104-105 >105
 5 cm
GI tract
5–8
Single
drug
Brain
liver
>8
2 or more
drugs
Management of Gestational Trophoblastic
Disease
Figure 2: Management of Trophoblastic Neoplasia
Figure 3: Management of Trophoblastic Neoplasia
Management of Trophoblastic
Disease
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 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.