Transcript Gestational Trophoblastic Disease

Gestational Trophoblastic Disease
DI WEN
2006-11-15 七年制
M.D., Ph.D.,
Professor & Chairman
Department Of Obstetrics & Gynecology
GTD
Renji Hospital
Affiliated to SJTU School of Medicine
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introduction
Defination:
gestational trophoblastic disease (GTD) is
a group of disease originated from
placental villose trophoblastic cells,
including hydatidiform mole, invasive
mole, choriocarcinoma and a kind of less
common trophoblastic cell tumor in
placenta.
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introduction
Relations among the diseases:
Benign mole is considered to be abnormal
formation of placenta accompanied by the special
abnormal hereditary ;
Invasive mole results from benign mole;
Choriocarcinoma and the trophoblastic cell tumor
in placenta may result from benign mole, term
pregnancy, abortion and ectopic pregnancy.
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Hydatidiform Mole
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Introduction
Defination: hydatidiform mole means that
after pregnancy the placental trophoblastic
cells proliferate abnormally, there is stromal
edema, and forms vesicula which is like grape
on its apparence.
Classification : hydatidiform mole is divided
into complete and incomplete type
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Etiology
the etiology is not clear
Etiology of complete hydatidiform mole
Epidemiology: the morbidity of hydatidiform mole is different in different
area.
High risk factors:
1.nourishing status,social economy.
2.age:over 35 and 40 years old;below 20 years old.
3.hydatidiform mole history:if a patient has the history of 1 or 2 times
hydatidiform mole,then the morbidity of the hydatidiform mole when
pregnant again is 1% and 15~20% respectively.
Genetic factors:
1.enucleate egg fertilization: chromosome karyotype of complete mole is
diploid ,90% is 46XX,10% is 46XY.
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Etiology
Etiology of incomplete hydatidiform mole
the morbidity of incomplete mole is much
lower than that of the complete type, and it
is not associated with age.
Genetic factors: chromosome karyotype of
90% incomplete mole is triploid. The most
common
chromosome
karyotype
is
69XXY,and then is 69XXX or 69XYY.
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Pathology
Complete mole
incomplete mole
-
+
Villus stromal edema
diffuseed
localized
Trophoblastic hyperplasia
diffuseed
localized
Villus outline
regular
irregular
Embryotic or fetal tissue
Villus stromal blood vessel
Karyotype
diploid
+
triploid or tetraploid
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Partial mole
Complete mole
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Partial mole
Complete mole
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Clinical manifestation
complete mole:
vaginal bleeding after amenorrhea
uterus is abnormally enlarged and become soft
hyperthyroidism
theca lutein ovarian cyst
gestational vomitting and PIH
Hyperthyroidism
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theca lutein ovarian cyst
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Clinical manifestation
partial mole:
may have the major symptoms of complete
mole but it is slightly manifested. no luteinizing
cyst. The histologic examination of curettage
sample may confirm the diagnosis.
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Prognosis
complete mole has the latent risk of local invasion
or telemetastasis
The high-risk factors includes
β-HCG>100000IU/L
uterine size is obviously larger than that with the same
gestational time.
the luteinizing cyst is >6cm
If >40 years old,the risk of invasion and metastasis may be
37%, If >50 years old,the risk of invasion and metastasis
may be 56%.
repeated mole:the morbidity of invasion and metastasis
increase 3~4 times
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Diagnosis
HCG measurement
ultrasound examination
detecting the fetal heart beat by ultrasound
Doppler
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Differential diagnosis
 abortion
 twin pregnancy
 polyhydramnios
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Management
emptying uterine cavity
once the diagnosis is confirmed the uterine
cavity should be emptied as soon as possible
Hysterectomy
over 40 years old with high-risk factors
uterine size is over 14 gestational weeks
management of luteinizing cyst
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Management
preventive chemotherapy
over 40 years old
the β-HCG is over 100kIU/L before emptying mole
the HCG regresion curve is not progressively
declined
uterus is obviously larger than the size of the
amenorrhea
luteinizing cyst is >6cm
there is still over hyperplasia of trophoblastic cells
in the second curettage
no follow up conditions
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Follow up
HCG qw till
QW X 3m
Q2W X 3m
QM X 6m
Q6M X 2y
normal
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Invasive mole
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introduction
 Definition:
Invasive mole means the
hydatidiform mole invade the uterine myometrium
or metastasize to extrauterine tissue.
 Biologic behavior:
invasive mole villus may
invade myometrium or blood vessels or both, at
beginning it spread locally,invade myometrium,
sometimes penetrate the uterine wall and spread to
the broad ligament or abdominal cavity.
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Pathology
 Macro examination: different size of viscula in
myometrium,there may be or may not be primary
focus in uterine cavity.when the invasion is near
serosal layer……
 Microexamination: villose structure and
trophoblastic cells proliferation and differentiation
deficiency.villose and trophoblastic cells can be
found in most patients,and cause vascular wall
necrosis and bleeding
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Clinical manifestation
 irregular vaginal bleeding
 uterine subinvolution
 theca lutein cyst does not disappear after
emptying uterus
 abdominal pain
 metastatic focus manifestation
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Diagnosis
history and clinical manifestation
successive measurement of HCG
ultrasound examination
X-ray and CT
histologic diagnosis
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Choriocarcinoma
2006-11-15 七年制
GTD
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Introduction
Choriocarcinoma is a highly malignant tumor,it can
metastasize to the whole body through blood
circulation , damage tissues and organs,cause bleeding
and necrosis.
The most common metastatic site is lung ,then
vagina,brain and liver
50%gestational choriocarcinoma result from
hydatidiform mole (generally occurs over 1 year after
emptying the mole), the rate of occurrence after
abortion or term delivery is 25% and 25% respectively,
seldom occurs after ectopic pregnancy
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Pathology
 macroexamination: most choriocarcinoma occurs in uterus,
the tumor diameter 2-10cm, its color, section, cancer
embolus is often found in parauterine veins,ovarian
luteinizing cyst may be formed
 histologic
examination: under microscope
the
hyperplastic cytotrophoblastic cells and syntrophoblastic
cells invade the myometrium and blood vessels
accompanied by the bleeding and necrosis, so the cancer
cells can not be found in the center
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Clinical manifestation
Vaginal bleeding
Pain
Uterine enlargement
Mass
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Diagnosis
Clinical Features
Ultrasonography
Human Chorionic Gonadotrophin
CT
X-ray
Pathology
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Differential diagnosis
 Hydatidiform mole
 Invasive mole
 Placental site trophoblastic tumors
 Rudimental placenta
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Metastases
Lung
Vagina
Brain
Liver
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anatomic staging
Stage I disease confined to uterus
Stage II gestational trophoblastic tumor extending
outside uterus but limited to genital structures
(adnexa, vagina, broad ligament)
Stage III
gestational trophoblastic disease
extending to lungs with or without known genital
tract involvement
Stage IV all other metastatic sites
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Management
Chemotherapy
Surgery
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Follow up
QM X 1 y
Q3M X 2 y
QY X 2y
Q2Y
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Thanks for Your Attention
DI WEN
2006-11-15 七年制
M.D., Ph.D.
Professor & Chairman
Department of Obstetrics & Gynecology
Renji Hospital
Affiliated to SJTU School of Medicine
GTD
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