chp 45- gestational trophoblastic neoplasia Flashcards
Persistent or malignant disease will develop in ___% of pt with molar pregnancy
20
Epidemiology of molar pregnancy
1/200 asian pregnancies > 1/1500 USA. Higher in women >35 or <20.
What is the recurrence rate of molar pregnancy?
1-2%
Risk factors for molar pregnancy
low dietary carotene consumption, vit A deficiency, history of infertility/sab
A mole includes abnormal proliferation of _____ and replacement of normal placental tissue by ____.
syncytiotrophoblast/ hydropic placental vili
Genetic constituents of complete moles
entirely paternal origin. Reduplicated haploid sperm or 2 sprem. Usually 46 XX and has no fetal parts.
Genetic constituents of partial moles.
triploid with one haploid maternal set and 2 haploid paternal sets.
T or F. Complete moles are MC than partial and are less likely to undergo malignant transformation.
F. They are mc but are more likely to undergo transformation.
Presentation of complete molar pregnancy
abnormal gestation, 50% will have large uterus, >25% will have bilateral theca lutein cysts,. Other s/s- exaggerated symptoms of pregnancy (N/V), painless 2nd trimester bleeding, lack of FHT, gestational htn, proteinuria (hyperrflexia), hyperthyroid (due to high hcg)
Presentation of partial molar pregnancy
missed abortion, small or appropriate sized uterus, Other s/s- exaggerated symptoms of pregnancy (N/V), painless 2nd trimester bleeding (less common), lack of FHT, gestational htn, proteinuria (hyperrflexia), hyperthyroid (due to high hcg)
Diagnosis of molar pregnancy
snowstorm USG,very high hcg
classification of malignant GTN
persistent nonmetastatic GTN, metastatic GTN (good prognosis, bad prognosis), placental site tumors (malignant, usually nonmetastatic)
In a woman with severe HTN before week 20, what should you suspect?
molar pregnancy
Definitive tx of molar pregnancy
uterine evacuation (dilation,suction, then gentle sharp curretage)
The _____ the uterus, the greater the risk of pulm complications associated with trophoblastic emboli, fluid overload, anemia.
larger
Despite removal of molar pregnancy, the risk of persistent GTN is ___
3-5%
What causes theca lutein cysts
follicular stimulation by high levels of hCG. spontaneously regress
Preop evaluation of molar pregnancy
baseline hcg, CXR, CBC, blood type an screen, blotting function studies, other tests if clinical evidence of hyperthyroidism and/or gestational HTN
What is postevac management for these pt?
monitor closely for 6-12 mo, give Rh- pt Rh Ig, check hCG 48 hrs after, every 1-2 weeks while elevated, and at 1-2 mo
The risk of recurrence after 1 year remission is __. The risk with future pregnancies is ___.
<1%, 1-2%
When is persistent GTN diagnosed?
when hcg levels dont fall after molar or normal pregnancy
An invasive mole is histologically identical to ____
complete mole
Appearance of choriocarcinomas
red, granular appearance with intermingled syncytiotrophoblast and cytotrophoblast elements
Describe path of choriocarcinomas
rapid myometrial and urterine vessel invasion and systemic mets from hematogenous emoblization. Lung, vagina, CNS, kidny, liver MCly.
How common are choriocarcinomas
1/150,000 pregs, 1/15000 abortions, 1/5000 ectopics, 1/40 molars
How is choriocarcinoma treated?
test hcg (esp w bleeding >6 wks after pregnancy). Single agent chemo (mtx or actinomycin D) for nonmetastatic disease, FIGO>7 requires multiagent chemo with EMACO.
Choriocharcinoma prognosis
5 year for nonmets and goodprog is 100%. For poor prog is 80%
What cells make up placental site tumors
monomorphic populations of intermediated cytotrophoblastic cells that are locally invasive
What do placental site tumors make?
small amounts of hcg. Better managed by hpl
How are placental tumors treated
hysterectomy
good prognosis GTN criteria
No risk factors, <40,000, no brain or liver mets, no antecedent term pregnancy, no prior chemo
Poor prognosis GTN criteria
more than 4 mo after pregnancy, pretherapy hCG >40,000, brain or liver mets, antecedent term pregnancy, prior chemo
